Provider Demographics
NPI:1396025821
Name:REVARD, BETH H (RT)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:H
Last Name:REVARD
Suffix:
Gender:F
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:38878 POLO CLUB DR
Mailing Address - Street 2:APT #102
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-5612
Mailing Address - Country:US
Mailing Address - Phone:248-790-3920
Mailing Address - Fax:
Practice Address - Street 1:38878 POLO CLUB DR
Practice Address - Street 2:APT #102
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48335-5612
Practice Address - Country:US
Practice Address - Phone:248-790-3920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1865112471C3401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed Tomography