Provider Demographics
NPI:1790774099
Name:REVOLINSKY, MARY C (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:C
Last Name:REVOLINSKY
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:26908 DETROIT RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-2398
Mailing Address - Country:US
Mailing Address - Phone:440-617-1823
Mailing Address - Fax:440-617-0884
Practice Address - Street 1:29325 HEALTH CAMPUS DR
Practice Address - Street 2:STE 2
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-8201
Practice Address - Country:US
Practice Address - Phone:440-835-6142
Practice Address - Fax:440-899-4383
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2020-11-13
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Provider Licenses
StateLicense IDTaxonomies
OH35062525207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00308460OtherRR MEDICARE
OH0903455Medicaid
OH0903455Medicaid
OHP00308460OtherRR MEDICARE
OH4162543Medicare PIN