1053482612 NPI number — DR. REVANORD PIERRE-LOUIS M.D.

Table of content: DR. REVANORD PIERRE-LOUIS M.D. (NPI 1053482612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053482612 NPI number — DR. REVANORD PIERRE-LOUIS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PIERRE-LOUIS
Provider First Name:
REVANORD
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053482612
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
158 W 27TH ST
Provider Second Line Business Mailing Address:
11 FL. SOUTH
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10001-6216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-563-2497
Provider Business Mailing Address Fax Number:
212-563-0605

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15211 89TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JAMAICA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11432-3730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-563-2497
Provider Business Practice Location Address Fax Number:
212-563-0605
Provider Enumeration Date:
11/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  194861 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01541313 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".