Revascmedprofessional NJ LLC

Primary specialty

Interventional Cardiology PhysicianTaxonomy code 207RI0011X

Legal business name

REVASCMEDPROFESSIONAL NJ LLC

Practice address

525 Route 73 N Ste 117
Marlton, NJ 08053-3422

Phone

(215) 575-5906

Fax

(215) 392-7992

NPI assigned

Mar 8, 2022

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Jon C George, MDNPI 1992746721

Title

Owner

Phone

(215) 575-5906

Specialties & licenses 2

Addresses

Other names 1

• REVAMP Doing business as

Medicare fee-for-service enrollment

Enrolled in NJ, PA2 enrollments

Enrollment records 2

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Jon C George, MD

  • Interventional Cardiology Physician
  • Philadelphia, PA
  • NPI 1992746721

  Cardiovascular Disease, NJ

  Medicare reassignment NPD Authorized official
• Courtney Destefano

  • Family Nurse Practitioner
  • Marlton, NJ
  • NPI 1780219410
  Medicare reassignment NPD
• Vincent Varghese, D.O.

  • Cardiovascular Disease Physician
  • Marlton, NJ
  • NPI 1316145808

  PA

  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1646697600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1646697600000",
    "number": "1154078202",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "525 ROUTE 73 N STE 117",
            "city": "MARLTON",
            "state": "NJ",
            "postal_code": "080533422",
            "telephone_number": "215-575-5906",
            "fax_number": "215-392-7992"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "525 ROUTE 73 N STE 117",
            "city": "MARLTON",
            "state": "NJ",
            "postal_code": "080533422",
            "telephone_number": "215-575-5906",
            "fax_number": "215-392-7992"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REVASCMEDPROFESSIONAL NJ LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-03-08",
        "last_updated": "2022-03-08",
        "certification_date": "2022-03-08",
        "status": "A",
        "authorized_official_last_name": "GEORGE",
        "authorized_official_first_name": "JON",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "215-575-5906",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207RC0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine, Cardiovascular Disease",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RI0011X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine, Interventional Cardiology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "REVAMP",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Eric Robert Requa, D.O.
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• Kelly Ann Rettberg, LPC
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• James Reyes, APN
• Samantha Elizabeth Reynolds, M.S. ATC LAT

• Interventional Cardiology Physician in Marlton, NJ
• Providers in Marlton, NJ by specialty
• Interventional Cardiology Physician in New Jersey

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 8, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.