Provider Demographics
NPI:1902867286
Name:REVTYAK, GEORGE E (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:E
Last Name:REVTYAK
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 N SENATE BLVD
Practice Address - Street 2:SUITE 310
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1228
Practice Address - Country:US
Practice Address - Phone:317-962-2500
Practice Address - Fax:317-962-2515
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE23373207RC0000X
IN01028670A207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1257717OtherIA MEDICAID
NE47076868513Medicaid
IN100324050Medicaid
INP00964726Medicare PIN
A03580Medicare UPIN
INP01194061Medicare PIN
INM400039528Medicare PIN
IN100324050Medicaid
NE47076868513Medicaid
INP00453102Medicare PIN
IN247020JMedicare PIN