Basic Information
| Provider Information | |||||||||
| NPI: | 1023739273 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REVERE | ||||||||
| FirstName: | EDWARD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 227 THORN AVE | ||||||||
| Address2: | |||||||||
| City: | ORCHARD PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141272600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166622040 | ||||||||
| FaxNumber: | 7166620019 | ||||||||
| Practice Location | |||||||||
| Address1: | 1021 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142121460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166622040 | ||||||||
| FaxNumber: | 7166620019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2022 | ||||||||
| LastUpdateDate: | 09/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | CRPA-5254 | NY | N | 175T00000X | NYCPS-P4548 | NY | Y |
No ID Information.