Provider Demographics
NPI:1407887573
Name:REVIS, SHELEY RENE' (MD)
Entity Type:Individual
Prefix:
First Name:SHELEY
Middle Name:RENE'
Last Name:REVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-1500
Mailing Address - Fax:704-384-1525
Practice Address - Street 1:8401 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE 250
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-8797
Practice Address - Country:US
Practice Address - Phone:704-384-1500
Practice Address - Fax:704-384-1525
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500197207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8971329Medicaid
NCNC9051AMedicare PIN
NC8971329Medicaid
NC22117071DMedicare PIN