Provider Demographics
NPI:1790143436
Name:REVELSTONE FAMILY PRACTICE
Entity Type:Organization
Organization Name:REVELSTONE FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:KEPP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-986-3900
Mailing Address - Street 1:232 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-4612
Mailing Address - Country:US
Mailing Address - Phone:704-986-3900
Mailing Address - Fax:704-986-3913
Practice Address - Street 1:232 CONCORD RD
Practice Address - Street 2:
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-4612
Practice Address - Country:US
Practice Address - Phone:704-986-3900
Practice Address - Fax:704-986-3913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-09
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400873207Q00000X
207Q00000X, 363LF0000X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8947986Medicaid
2344328Medicare UPIN