Basic Information
| Provider Information | |||||||||
| NPI: | 1740240647 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REAVILL | ||||||||
| FirstName: | OLGA | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 365 PACIFIC ST | ||||||||
| Address2: | |||||||||
| City: | LONG BRANCH | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077407274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372554081 | ||||||||
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| Practice Location | |||||||||
| Address1: | 731 HWY 35 UNIT G | ||||||||
| Address2: | |||||||||
| City: | OCEAN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077124765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7324558444 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 08/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD.L07184R | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207L00000X | H6764 | TX | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207Q00000X | MD.L07184R | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 207L00000X | 25MA10701700 | NJ | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | DISP.200276 | 01 | LA | DISPENSING REGISTRATION | OTHER | 1388441 | 05 | LA | MEDICAID |