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Individual

CHARLES THEODORE REVELEY JR.

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
Man
Credential
MD

Contact information

Practice address
400 OFFICE PARK DR, SUITE 110, MOUNTAIN BRK, AL 35223-3408
(205) 870-8415
Mailing address
400 OFFICE PARK DR, SUITE 110, BIRMINGHAM, AL 35223-3408
(205) 870-8415

Taxonomy

Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
MD.28076
AL

Other

Other identifiers
Code
Description
Identifier
Issuer
State
01
051531151
BLUE CROSS
AL
01
051531152
BC FEDERAL EHBP
AL
01
515-92203
BLUECROSS BLUESHIELD
AL
Enumeration date
07/11/2006
Last updated
04/07/2012
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