Healthcare Provider Details

I. General information

NPI: 1619404530
Provider Name (Legal Business Name): PATRICK KEVIN REVILLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2017
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 MAPLE ST
NORWALK CT
06850-3894
US

IV. Provider business mailing address

34 MAPLE ST
NORWALK CT
06850-3894
US

V. Phone/Fax

Practice location:
  • Phone: 203-845-4811
  • Fax:
Mailing address:
  • Phone: 216-312-4431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number081263
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: