Provider Demographics
NPI:1134151921
Name:REVELL, WILLIAM SAMUEL (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:SAMUEL
Last Name:REVELL
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1656 RIVERCHASE BLVD
Practice Address - Street 2:STE 3600
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2084
Practice Address - Country:US
Practice Address - Phone:803-324-7606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27967207V00000X
SC11222207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1134151921Medicaid
SC112229Medicaid
NC89066W9Medicaid
NC71325OtherNC BLUE CROSS BLUE SHIELD
NC8971325Medicaid
SC112229Medicaid
NC89066W9Medicaid
SCC861337165Medicare PIN
NC209885CMedicare PIN
NC71325OtherNC BLUE CROSS BLUE SHIELD