Healthcare Provider Details

I. General information

NPI: 1083175541
Provider Name (Legal Business Name): SHELLEY REVESZ DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 RITCHIE HWY STE 209
ARNOLD MD
21012-2741
US

IV. Provider business mailing address

1460 RITCHIE HWY STE 209
ARNOLD MD
21012-2741
US

V. Phone/Fax

Practice location:
  • Phone: 410-789-7337
  • Fax:
Mailing address:
  • Phone: 410-789-7337
  • Fax: 859-323-1315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number05223
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberH0097709
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: