Basic Information
| Provider Information | |||||||||
| NPI: | 1619127024 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REVANKAR | ||||||||
| FirstName: | MANASI | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 OSTRUM ST | ||||||||
| Address2: | ST. LUKE'S ENROLLMENT CENTER | ||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4845268046 | ||||||||
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| Practice Location | |||||||||
| Address1: | 185 ROSEBERRY ST | ||||||||
| Address2: | |||||||||
| City: | PHILLIPSBURG | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088651690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4845266643 | ||||||||
| FaxNumber: | 4845264658 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2008 | ||||||||
| LastUpdateDate: | 09/02/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25MB09074300 | NJ | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 262304 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.