Provider Demographics
NPI:1730139270
Name:REVITTE, THOMAS J (NP)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:J
Last Name:REVITTE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5010 GULL RD
Mailing Address - Street 2:STE A
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1093
Mailing Address - Country:US
Mailing Address - Phone:269-226-8800
Mailing Address - Fax:269-226-8804
Practice Address - Street 1:5010 GULL RD
Practice Address - Street 2:STE A
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1093
Practice Address - Country:US
Practice Address - Phone:269-226-8800
Practice Address - Fax:269-226-8804
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704216398363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4546810Medicaid
MI50087018880OtherBLUE CROSS & BLUE SHIELD
MI4546810Medicaid
MIOC96013Medicare ID - Type UnspecifiedMEDICARE GROUP #