Provider Demographics
NPI:1073593570
Name:82 MEDICAL GROUP
Entity Type:Organization
Organization Name:82 MEDICAL GROUP
Other - Org Name:U.S. AIR FORCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPER
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:REVIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:940-676-4945
Mailing Address - Street 1:149 HART ST
Mailing Address - Street 2:
Mailing Address - City:SHEPPARD AFB
Mailing Address - State:TX
Mailing Address - Zip Code:76311-3477
Mailing Address - Country:US
Mailing Address - Phone:940-676-6075
Mailing Address - Fax:940-676-6076
Practice Address - Street 1:149 HART ST
Practice Address - Street 2:
Practice Address - City:SHEPPARD AFB
Practice Address - State:TX
Practice Address - Zip Code:76311-3477
Practice Address - Country:US
Practice Address - Phone:940-676-6075
Practice Address - Fax:940-676-6076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23872261QM0801X
261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Not Answered261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN