=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609210350
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVOLUTIONARY HEALTH SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2013
-----------------------------------------------------
Last Update Date | 04/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1121 GENERAL WASHINGTON MEM BLVD
-----------------------------------------------------
City | WASHINGTON CROSSING
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18977-1366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-321-1371
-----------------------------------------------------
Fax | 215-321-1378
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1121 GENERAL WASHINGTON MEM BLVD
-----------------------------------------------------
City | WASHINGTON CROSSING
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18977-1366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-321-1371
-----------------------------------------------------
Fax | 215-321-1378
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICIAN
-----------------------------------------------------
Name | CHARLES WHITNEY III
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 215-321-1371
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD048097L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------