Matthew Charles Revilla, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

9684 Issued in GA

Practice address

507 Park St
Palmetto, GA 30268-1007

Phone

(770) 463-4644

NPI assigned

Apr 9, 2020

Last updated

Aug 27, 2021By the provider in NPPES

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in GA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Other, 2019

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

The Emory Clinic IncGroup PAC ID 8820901408, 3,507 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Emory University Hospital Midtown Hospital, Atlanta, GA, CCN 110078

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: mrevilla1036806@direct.emory.org

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

• The Emory Clinic Inc

  • Internal Medicine Physician
  • Atlanta, GA
  • NPI 1396798229
  Medicare reassignment Care Compare group NPD

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

• Crawford Long Hospital

  dba Emory University dba Emory Crawford Long Hospital

  • General Acute Care Hospital
  • Atlanta, GA
  • NPI 1144203563
  Care Compare affiliation

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

{
    "created_epoch": "1586390400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1630022400000",
    "number": "1821617036",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "643 MAIN ST",
            "city": "PALMETTO",
            "state": "GA",
            "postal_code": "302681138",
            "telephone_number": "404-929-8824"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "507 PARK ST",
            "city": "PALMETTO",
            "state": "GA",
            "postal_code": "302681007",
            "telephone_number": "770-463-4644"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2584 Patrick Ct SE",
            "address_purpose": "LOCATION",
            "city": "Atlanta",
            "state": "GA",
            "postal_code": "303173023",
            "country_code": "US",
            "telephone_number": "252-414-8145",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "REVILLA",
        "first_name": "MATTHEW",
        "middle_name": "CHARLES",
        "credential": "PA-C",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2020-04-09",
        "last_updated": "2021-08-27",
        "certification_date": "2021-08-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "GA",
            "license": "9684",
            "primary": true
        },
        {
            "code": "207QA0505X",
            "taxonomy_group": "",
            "desc": "Family Medicine, Adult Medicine",
            "state": "GA",
            "license": "9684",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Powerback Rehabilitation LLC (Powerback Rehabilitation)
• Premier Personal Health Services, LLC (Premier Cla)
• Ilamae Price
• Jennifer Quetant
• Renal Treatment Centers Mid Atlantic Inc (Fairburn Palmetto Dialysis)
• Jennifer Dionisia Rivera, DOULA
• Sacred Heart Home LLLP
• Sacred Heart Transportation LLC
• Brittany Shea Sandlin, CCC-SLP
• Lyzette Santiago Rodriguez, LPC

• Physician Assistant in Palmetto, GA
• Providers in Palmetto, GA by specialty
• Physician Assistant in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 27, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.