Provider Demographics
NPI:1225212061
Name:REVELL, SALLY M (MD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:M
Last Name:REVELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SALLY
Other - Middle Name:P
Other - Last Name:MERRYMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:148 BILL CARRUTH PKWY
Mailing Address - Street 2:STE 220
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-3754
Mailing Address - Country:US
Mailing Address - Phone:770-505-0023
Mailing Address - Fax:770-505-9848
Practice Address - Street 1:699 CHURCH ST NE
Practice Address - Street 2:STE 340
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060
Practice Address - Country:US
Practice Address - Phone:770-793-7613
Practice Address - Fax:770-793-7413
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA65884207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology