MEDICARE: REVV MEDICAL DIAGNOSTIC PC

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
1	174400000X	Specialist

General Provider Information

NPI Number	:	1255663910
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVV MEDICAL DIAGNOSTIC PC

Provider Business Mailing Address
First Line	:	201 PORTION RD
Second Line	:	SUITE B
City	:	RONKONKOMA
State	:	NY
Zip	:	11779-4172
Country	:	US
Telephone Number	:	516-872-7001
Fax Number	:	516-872-7015

Provider Business Practice Location Address
First Line	:	201 PORTION RD
Second Line	:	SUITE B
City	:	RONKONKOMA
State	:	NY
Zip	:	11779-4172
Country	:	US
Telephone Number	:	516-872-7001
Fax Number	:	516-872-7015

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LEE S MARCUS
Credential	:	MD
Telephone Number	:	516-872-7001

Provider Enumeration Date	:	02/05/2010
Last Update Date	:	02/17/2011

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