Provider Demographics
NPI:1659150696
Name:REAVIS, GENE CASAMERA III (CO)
Entity Type:Individual
Prefix:
First Name:GENE
Middle Name:CASAMERA
Last Name:REAVIS
Suffix:III
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 S 55TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-4005
Mailing Address - Country:US
Mailing Address - Phone:215-474-4767
Mailing Address - Fax:
Practice Address - Street 1:901 S 55TH ST UNIT A2
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19143-4005
Practice Address - Country:US
Practice Address - Phone:215-474-4767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACO264177335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier