Revan LLC

Primary specialty

Undersea and Hyperbaric Medicine (Emergency Medicine) PhysicianTaxonomy code 207PE0005X

License

OS4598 Issued in FL

Legal business name

REVAN LLC

Practice address

3890 Tampa Rd Ste 201
Palm Harbor, FL 34684-3677

Phone

(727) 781-3111

Fax

(727) 781-3113

NPI assigned

Apr 20, 2006

Organization subpart

No

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

Authorized official

Name

Charles Boothby, D.O.

Title

Owner

Phone

(727) 869-5551

Specialties & licenses 1

Addresses

Other identifiers 2

Other names 1

• d/b/a Wound Management Former legal business name

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

{
    "created_epoch": "1145491200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1435708800000",
    "number": "1730145673",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 25513",
            "city": "TAMPA",
            "state": "FL",
            "postal_code": "336225513",
            "telephone_number": "727-823-2188",
            "fax_number": "727-828-0723"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3890 TAMPA RD STE 201",
            "city": "PALM HARBOR",
            "state": "FL",
            "postal_code": "346843677",
            "telephone_number": "727-781-3111",
            "fax_number": "727-781-3113"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REVAN LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-04-20",
        "last_updated": "2015-07-01",
        "status": "A",
        "authorized_official_last_name": "BOOTHBY",
        "authorized_official_first_name": "CHARLES",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "727-869-5551",
        "authorized_official_credential": "D.O."
    },
    "taxonomies": [
        {
            "code": "207PE0005X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Emergency Medicine, Undersea and Hyperbaric Medicine",
            "state": "FL",
            "license": "OS4598",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "069165800",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS FL",
            "identifier": "82569",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "d/b/a Wound Management",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

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• Sharon Lisa Rhodes, PTA
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• Undersea and Hyperbaric Medicine (Emergency Medicine) Physician in Palm Harbor, FL
• Providers in Palm Harbor, FL by specialty
• Undersea and Hyperbaric Medicine (Emergency Medicine) Physician in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 1, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.