Provider Demographics
NPI:1619562386
Name:REVENNAUGH, MATTHEW JAMES (PA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
Last Name:REVENNAUGH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1100 REID PARKWAY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374
Mailing Address - Country:US
Mailing Address - Phone:659-358-8027
Mailing Address - Fax:765-983-3219
Practice Address - Street 1:1400 HIGHLAND RD STE 1
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-8810
Practice Address - Country:US
Practice Address - Phone:765-935-8905
Practice Address - Fax:765-939-4200
Is Sole Proprietor?:No
Enumeration Date:2021-03-04
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN10003154A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300048991Medicaid