MEDICARE: MR. JEFFREY J REVILL 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	207Q00000X	Family Medicine Physician	35.098156	OH
2	207P00000X	Emergency Medicine Physician	37837	TN
3	207Q00000X	Family Medicine Physician	C3932	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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679567523
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEFFREY J REVILL MD

Provider Business Mailing Address
First Line	:	1530 CENTER STAR ROAD
Second Line	:
City	:	COLUMBIA
State	:	TN
Zip	:	38401
Country	:	US
Telephone Number	:	931-626-0117
Fax Number	:	931-380-3640

Provider Business Practice Location Address
First Line	:	1530 CENTER STAR RD
Second Line	:
City	:	COLUMBIA
State	:	TN
Zip	:	38401
Country	:	US
Telephone Number	:	931-626-0117
Fax Number	:	931-380-3640

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

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	12/23/2025

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