Provider Demographics
NPI:1174682637
Name:REVIS, JOHN MARK (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARK
Last Name:REVIS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2650 RIDGE AVE
Mailing Address - Street 2:EVANSTON HOSPITAL
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1718
Mailing Address - Country:US
Mailing Address - Phone:847-570-1206
Mailing Address - Fax:847-570-1248
Practice Address - Street 1:1435 WAUKEGAN RD
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-2120
Practice Address - Country:US
Practice Address - Phone:847-832-6500
Practice Address - Fax:847-724-5379
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2020-10-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036-080976207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL110191370OtherRAILROAD MEDICARE PIN
ILE71137Medicare UPIN
ILL78191Medicare PIN