Basic Information
| Provider Information | |||||||||
| NPI: | 1619562386 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REVENNAUGH | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 REID PARKWAY | ||||||||
| Address2: | MEDICAL STAFF SERVICES | ||||||||
| City: | RICHMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6593588027 | ||||||||
| FaxNumber: | 7659833219 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 HIGHLAND RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473748810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7659358905 | ||||||||
| FaxNumber: | 7659394200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2021 | ||||||||
| LastUpdateDate: | 09/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 10003154A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 300048991 | 05 | IN | MEDICAID |