NPIMap

Individual provider Active NPI

Vicki Sue Revak, MSN, AGAC-BC

  • Gerontology Nurse Practitioner
  • Horsham, PA
National Provider Identifier
1972075356
Registry record updated Jun 24, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Gerontology Nurse PractitionerTaxonomy code 363LG0600X
License
SP019667 Issued in PA
Practice address
680 Blair Mill Rd
Horsham, PA 19044-2223
Phone
(267) 261-4413
NPI assigned
Dec 22, 2018
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 24, 2019

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Gerontology Nurse Practitioner 363LG0600X SP019667 PA Primary

Addresses

Primary practice location

680 Blair Mill Rd
Horsham, PA 19044-2223

Mailing address

10757 Pont Rd
Albion, PA 16401-8605
Phone (814) 336-4865

Other names 1

  • Vicki Sue Kaiser Former name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OH
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
I20231026003050 OH Practitioner - Nurse Practitioner 1456690288 Reassigns benefits to 4 organizations

Care Compare profile

Medicare Care Compare
Specialty
Nurse Practitioner
Education
Other, 2018
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
University Hospitals Medical Group IncGroup PAC ID 4789682493, 2,248 clinicians
University Hospitals Conneaut Medical CenterGroup PAC ID 0547429656, 8 clinicians
University Hospitals Geneva Medical CenterGroup PAC ID 1658568803, 17 clinicians

Practice addresses (Care Compare)

11100 Euclid Ave
Cleveland, OH 44106-1716

158 W Main Rd
Conneaut, OH 44030-2039
Phone (440) 593-0122

870 W Main St
Geneva, OH 44041-1219
Phone (440) 466-1141

Hospital & facility affiliations

  • University Hospitals Conneaut Medical Center Hospital, Conneaut, OH, CCN 361308
  • Uhhs Memorial Hospital of Geneva Hospital, Geneva, OH, CCN 361307
  • Uh Regional Hospitals Hospital, Chardon, OH, CCN 360075
  • Uh Cleveland Medical Center Hospital, Cleveland, OH, CCN 360137

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Certified Nurse Practitioner, Master of Science - Nursing

State licenses

LicenseStateTypeSpecialty
SP019667PAMDGerontology Nurse Practitioner

Practice roles

OrganizationSpecialtyStatusNew patients
University Hospitals Geneva Medical Center CurrentSince Sep 19, 2023 Accepting new patients
University Hospitals Conneaut Medical Center CurrentSince Sep 19, 2023 Accepting new patients
University Hospitals Medical Group Inc CurrentSince Dec 1, 2025 Accepting new patients
University Hospitals Ahuja Medical Center CurrentSince Apr 8, 2024 Accepting new patients
University Hospitals Conneaut Medical Center CurrentSince Sep 19, 2023 Accepting new patients
University Hospitals Ahuja Medical Center, Inc Current Accepting new patients
University Hospitals Ahuja Medical Center CurrentSince Apr 8, 2024 Accepting new patients

Locations

3999 Richmond Rd
Cleveland, OH 44122
Phone (216) 293-8226

11100 Euclid Ave
Cleveland Heights, OH 44106

158 W Main Rd
Conneaut, OH 44030
Phone (216) 844-3777

870 W Main St
Geneva, OH 44041
Phone (440) 415-0258

Interoperability endpoints

  • Direct secure messaging: vrevak220456@ehrdirect.uhhospitals.org

Organizations & group practices 7

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 7

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

NPI Registry JSON

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

{
    "created_epoch": "1545436800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1561334400000",
    "number": "1972075356",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10757 PONT RD",
            "city": "ALBION",
            "state": "PA",
            "postal_code": "164018605",
            "telephone_number": "814-336-4865"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "680 BLAIR MILL RD",
            "city": "HORSHAM",
            "state": "PA",
            "postal_code": "190442223",
            "telephone_number": "267-261-4413"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "REVAK",
        "first_name": "VICKI",
        "middle_name": "SUE",
        "credential": "MSN, AGAC-BC",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2018-12-22",
        "last_updated": "2019-06-24",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LG0600X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Gerontology",
            "state": "PA",
            "license": "SP019667",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "VICKI",
            "last_name": "KAISER",
            "middle_name": "SUE",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

Other providers in Horsham, PA

Sources for this page

Verify at the official NPI Registry.