Healthcare Provider Details

I. General information

NPI: 1316915952
Provider Name (Legal Business Name): JAMES R REVENAUGH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 04/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5169 COTTONWOOD ST BLDG. B, SUITE 520
MURRAY UT
84107-6767
US

IV. Provider business mailing address

5169 COTTONWOOD ST BLDG. B, SUITE 520
MURRAY UT
84107-6767
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-3500
  • Fax: 801-507-3550
Mailing address:
  • Phone: 801-507-3500
  • Fax: 801-507-3550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number333439
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: