MEDICARE: REVAN LLC

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	207PE0005X	Undersea and Hyperbaric Medicine (Emergency Medicine) Physician	OS4598	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	82569	OTHER	FL	BCBS FL

General Provider Information

NPI Number	:	1730145673
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVAN LLC

Provider Business Mailing Address
First Line	:	PO BOX 25513
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33622-5513
Country	:	US
Telephone Number	:	727-823-2188
Fax Number	:	727-828-0723

Provider Business Practice Location Address
First Line	:	3890 TAMPA RD STE 201
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34684-3677
Country	:	US
Telephone Number	:	727-781-3111
Fax Number	:	727-781-3113

Authorized Official
Title or Position	:	OWNER
Name	:	CHARLES BOOTHBY
Credential	:	D.O.
Telephone Number	:	727-869-5551

Provider Enumeration Date	:	04/20/2006
Last Update Date	:	07/01/2015

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Directions to “REVAN LLC ” Practice Location

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