Provider Demographics
NPI:1760418610
Name:REVILLA, FREDY JESUS (MD)
Entity Type:Individual
Prefix:
First Name:FREDY
Middle Name:JESUS
Last Name:REVILLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWOOD DR STE B350
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6337
Practice Address - Country:US
Practice Address - Phone:864-454-4500
Practice Address - Fax:864-454-4505
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350834172084N0400X
SC376412084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2463614Medicaid
SC376417Medicaid
OHP00113175OtherMEDICARE RAILROAD
OH2463614Medicaid
SCSC49827951-UMGMedicare PIN
OHP00113175OtherMEDICARE RAILROAD
OHH040210Medicare PIN