Healthcare Provider Details

I. General information

NPI: 1609210350
Provider Name (Legal Business Name): REVOLUTIONARY HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2013
Last Update Date: 04/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 GENERAL WASHINGTON MEM BLVD
WASHINGTON CROSSING PA
18977-1366
US

IV. Provider business mailing address

1121 GENERAL WASHINGTON MEM BLVD
WASHINGTON CROSSING PA
18977-1366
US

V. Phone/Fax

Practice location:
  • Phone: 215-321-1371
  • Fax: 215-321-1378
Mailing address:
  • Phone: 215-321-1371
  • Fax: 215-321-1378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD048097L
License Number StatePA

VIII. Authorized Official

Name: CHARLES WHITNEY III
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 215-321-1371