Organization
REVAN LLC
Active
Other names
d/b/a Wound Management
Organization subpart
No
Provider details
NPI number
Authorized official
CHARLES BOOTHBY D.O. (OWNER)
(727) 869-5551
Entity
Organization
Contact information
Practice address
3890 TAMPA RD STE 201, PALM HARBOR, FL 34684-3677
(727) 781-3111
(727) 781-3113
Mailing address
PO BOX 25513, TAMPA, FL 33622-5513
(727) 823-2188
(727) 828-0723
Taxonomy
Speciality
Code
Description
License number
State
207PE0005X
Undersea and Hyperbaric Medicine (Emergency Medicine) Physician
Primary
OS4598
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
069165800
—
FL
01
—
82569
BCBS FL
FL
Enumeration date
04/20/2006
Last updated
07/01/2015
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