Provider Demographics
NPI:1679567523
Name:REVILL, JEFFREY J (MD)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:J
Last Name:REVILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 CENTER STAR ROAD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401
Mailing Address - Country:US
Mailing Address - Phone:931-626-0117
Mailing Address - Fax:931-380-3640
Practice Address - Street 1:1530 CENTER STAR RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401
Practice Address - Country:US
Practice Address - Phone:931-626-0117
Practice Address - Fax:931-380-3640
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37837207P00000X
OH35.098156207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0056324Medicaid
TN3897284Medicaid
TNI09585Medicare UPIN
OHH038832Medicare PIN