Provider Demographics
NPI:1265532923
Name:KREVOLIN, LARRY E (DO)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:E
Last Name:KREVOLIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 N BROAD ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-1511
Mailing Address - Country:US
Mailing Address - Phone:215-762-7785
Mailing Address - Fax:215-568-6007
Practice Address - Street 1:235 N BROAD ST
Practice Address - Street 2:SUITE 200 CLINICAL NEPHROLOGY ASSOC
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-1511
Practice Address - Country:US
Practice Address - Phone:215-762-7785
Practice Address - Fax:215-568-6007
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PA05003817L207RN0300X
NJ25MB03667100207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000792539Medicaid
PA000792539Medicaid
E63486Medicare UPIN
NJ063668Q87Medicare PIN