MEDICARE: WILLIAM ROBERT REVELETTE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	31337	KY
2	2080A0000X	Pediatric Adolescent Medicine Physician	31337	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639146996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM ROBERT REVELETTE MD

Provider Business Mailing Address
First Line	:	215 E 11TH ST
Second Line	:
City	:	NEWPORT
State	:	KY
Zip	:	41071-2203
Country	:	US
Telephone Number	:	859-655-6100
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 ORCHARD DR
Second Line	:
City	:	NICHOLASVILLE
State	:	KY
Zip	:	40356-2690
Country	:	US
Telephone Number	:	859-881-4288
Fax Number	:	859-881-4388

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2006
Last Update Date	:	06/24/2024

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