Provider Demographics
NPI:1659552792
Name:NEVILLE, LEVERETT C
Entity Type:Individual
Prefix:
First Name:LEVERETT
Middle Name:C
Last Name:NEVILLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 MARTHA BERRY BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1612
Mailing Address - Country:US
Mailing Address - Phone:706-291-2077
Mailing Address - Fax:
Practice Address - Street 1:1104 MARTHA BERRY BLVD NE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1612
Practice Address - Country:US
Practice Address - Phone:706-291-2077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-16
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0621452085R0202X, 2085N0700X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA581088313AOtherMEDICARE GROUP PROVIDER #
GA1659552792Medicare PIN