Healthcare Provider Details

I. General information

NPI: 1700249547
Provider Name (Legal Business Name): PAOLA REVECO DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 02/09/2021
Certification Date: 02/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DIAMOND HILL RD
BERKELEY HEIGHTS NJ
07922-2104
US

IV. Provider business mailing address

5645 MAIN ST
FLUSHING NY
11355-5045
US

V. Phone/Fax

Practice location:
  • Phone: 908-273-4300
  • Fax:
Mailing address:
  • Phone: 201-988-0685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number299096
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number25MB10917600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: