Provider Demographics
NPI:1427350339
Name:STEPHANIE M REVELS MD PA
Entity type:Organization
Organization Name:STEPHANIE M REVELS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:REVELS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:913-484-5052
Mailing Address - Street 1:8249 W 95TH ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66212-3217
Mailing Address - Country:US
Mailing Address - Phone:913-484-5052
Mailing Address - Fax:
Practice Address - Street 1:8249 W 95 TH STREET
Practice Address - Street 2:SUITE 108
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-3200
Practice Address - Country:US
Practice Address - Phone:913-484-5052
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-29
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0428042305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service