NPIMap

Individual provider Active NPI

Fredy Jesus Revilla, M.D.

  • Neurology Physician
  • Greenville, SC
National Provider Identifier
1760418610
Registry record updated Jun 29, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Neurology PhysicianTaxonomy code 2084N0400X
License
37641 Issued in SC
Practice address
200 Patewood Dr Ste B350
Greenville, SC 29615-6337
Phone
(864) 454-4500
Fax
(864) 454-4505
NPI assigned
Jun 23, 2006
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 29, 2021

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Neurology Physician 2084N0400X 35083417 OH
Neurology Physician 2084N0400X 37641 SC Primary

Addresses

Primary practice location

200 Patewood Dr Ste B350
Greenville, SC 29615-6337

Mailing address

300 E McBee Ave FL 4
Greenville, SC 29601-2842
Phone (864) 522-8603

Other identifiers 3

IdentifierTypeStateIssuer
2463614MedicaidOH
376417MedicaidSC
P00113175OtherOHMEDICARE RAILROAD

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address frevillarondon7327@direct.ghs.myhfn.org Direct

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20150216001032 SC Practitioner - Neurology 5799671764 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Neurology
Education
Other, 1993
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

200 Patewood Dr
Suite B350
Greenville, SC 29615-6337
Phone (864) 454-4500

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
35083417OHMDNeurology Physician
37641SCMDNeurology Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Greenville Health System CurrentSince Jan 5, 2015 Accepting new patients
Greenville Health System Current Accepting new patients
University Neurology Inc Neurology Past Accepting new patients

Locations

22725 US Highway 76
Clinton, SC 29325
Phone (864) 833-9100

200 Patewood Dr
Bldg A
Greenville, SC 29615
Phone (864) 454-2604

701 Grove Rd
Greenville, SC 29605
Phone (864) 454-2030

1 Independence Pt
Ste 212
Greenville, SC 29615
Phone (864) 797-6306

175 Patewood Dr
Greenville, SC 29615
Phone (864) 797-1000

298 Memorial Dr
Seneca, SC 29672
Phone (864) 482-3100

Interoperability endpoints

  • Direct secure messaging: frevillarondon7327@direct.ghs.myhfn.org

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 49

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 49

NPI Registry JSON

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

{
    "created_epoch": "1151020800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1624924800000",
    "number": "1760418610",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "300 E MCBEE AVE FL 4",
            "city": "GREENVILLE",
            "state": "SC",
            "postal_code": "296012842",
            "telephone_number": "864-522-8603"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "200 PATEWOOD DR STE B350",
            "city": "GREENVILLE",
            "state": "SC",
            "postal_code": "296156337",
            "telephone_number": "864-454-4500",
            "fax_number": "864-454-4505"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "REVILLA",
        "first_name": "FREDY",
        "middle_name": "JESUS",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-06-23",
        "last_updated": "2021-06-29",
        "certification_date": "2021-06-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2084N0400X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Neurology",
            "state": "OH",
            "license": "35083417",
            "primary": false
        },
        {
            "code": "2084N0400X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Neurology",
            "state": "SC",
            "license": "37641",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2463614",
            "state": "OH"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "376417",
            "state": "SC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE RAILROAD",
            "identifier": "P00113175",
            "state": "OH"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "frevillarondon7327@direct.ghs.myhfn.org",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "frevillarondon7327@direct.ghs.myhfn.org",
            "address_1": "200 Patewood Dr Ste B350",
            "city": "Greenville",
            "state": "SC",
            "country_code": "US",
            "postal_code": "296156337",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Greenville, SC

Sources for this page

Verify at the official NPI Registry.