Healthcare Provider Details

I. General information

NPI: 1225212061
Provider Name (Legal Business Name): SALLY M. REVELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SALLY P MERRYMAN MD

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 10/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

699 CHURCH ST NE STE 340
MARIETTA GA
30060
US

IV. Provider business mailing address

148 BILL CARRUTH PKWY STE 220
HIRAM GA
30141-3754
US

V. Phone/Fax

Practice location:
  • Phone: 770-793-7613
  • Fax: 770-793-7413
Mailing address:
  • Phone: 770-505-0023
  • Fax: 770-505-9848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number65884
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: