Provider Demographics
NPI:1245265982
Name:REVELEY, CHARLES THEODORE JR (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:THEODORE
Last Name:REVELEY
Suffix:JR
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 1:400 OFFICE PARK DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35223-3408
Mailing Address - Country:US
Mailing Address - Phone:205-870-8415
Mailing Address - Fax:
Practice Address - Street 1:400 OFFICE PARK DR
Practice Address - Street 2:SUITE 110
Practice Address - City:MOUNTAIN BRK
Practice Address - State:AL
Practice Address - Zip Code:35223-3408
Practice Address - Country:US
Practice Address - Phone:205-870-8415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2012-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.280762084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051531152OtherBC FEDERAL EHBP
AL515-92203OtherBLUECROSS BLUESHIELD
AL051531151OtherBLUE CROSS
AL051531151OtherBLUE CROSS
AL515-92203OtherBLUECROSS BLUESHIELD
AL051531151Medicare PIN