Basic Information
| Provider Information | |||||||||
| NPI: | 1295714558 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REVELLE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1804 HIGHWAY 45 BYP | ||||||||
| Address2: | SUITE 604 | ||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383054436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316608759 | ||||||||
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| Practice Location | |||||||||
| Address1: | 708 W FOREST AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316608759 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 07/16/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD34579 | TN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00109858 | 01 | RR MEDICARE | OTHER | 3861019 | 05 | TN | MEDICAID | 4032737 | 01 | BCBS | OTHER |