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NPI Code Detail

MEDICARE: JOHN MARK REVIS MD

MEDICARE: JOHN MARK REVIS MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207R00000XInternal Medicine Physician036-080976IL

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1110191370OTHERILRAILROAD MEDICARE PIN

General Provider Information

NPI Number : 1174682637
Entity Type Code : Individual
Provider Name (Legal Business Name) : JOHN MARK REVIS MD
Provider Business Mailing Address
First Line : 2650 RIDGE AVE
Second Line : EVANSTON HOSPITAL
City : EVANSTON
State : IL
Zip : 60201-1718
Country : US
Telephone Number : 847-570-1206
Fax Number : 847-570-1248
Provider Business Practice Location Address
First Line : 1435 WAUKEGAN RD
Second Line :
City : GLENVIEW
State : IL
Zip : 60025-2120
Country : US
Telephone Number : 847-832-6500
Fax Number : 847-724-5379
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/08/2006
Last Update Date : 10/06/2020

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