MEDICARE: MARY KIRSTYLEIGH ANN REVILLA LIM M.D

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	208000000X	Pediatrics Physician	32481901	NY

General Provider Information

NPI Number	:	1376168344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY KIRSTYLEIGH ANN REVILLA LIM M.D

Provider Business Mailing Address
First Line	:	506 LENOX AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10037-1802
Country	:	US
Telephone Number	:	212-939-4019
Fax Number	:	212-939-4022

Provider Business Practice Location Address
First Line	:	506 LENOX AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10037-1802
Country	:	US
Telephone Number	:	212-939-4019
Fax Number	:	212-939-4022

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2020
Last Update Date	:	06/01/2026

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