Provider Demographics
NPI:1316915952
Name:REVENAUGH, JAMES R (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:R
Last Name:REVENAUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5169 COTTONWOOD ST
Mailing Address - Street 2:BLDG. B, SUITE 520
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6767
Mailing Address - Country:US
Mailing Address - Phone:801-507-3500
Mailing Address - Fax:801-507-3550
Practice Address - Street 1:5169 COTTONWOOD ST
Practice Address - Street 2:BLDG. B, SUITE 520
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6767
Practice Address - Country:US
Practice Address - Phone:801-507-3500
Practice Address - Fax:801-507-3550
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT333439207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002084158Medicaid
ID805051500Medicaid
UTD1851Medicaid
060052374OtherRR MEDICARE
WY113027700Medicaid
UTF82980Medicare UPIN
WY113027700Medicaid
NVV100428Medicare PIN