Provider Demographics
NPI:1285837492
Name:REVIVAL ORTHOPAEDICS INC
Entity Type:Organization
Organization Name:REVIVAL ORTHOPAEDICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIDGES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-694-9400
Mailing Address - Street 1:1190 NW 95TH ST
Mailing Address - Street 2:SUITE 305
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33150-2063
Mailing Address - Country:US
Mailing Address - Phone:305-694-9400
Mailing Address - Fax:305-693-6942
Practice Address - Street 1:1190 NW 95TH ST
Practice Address - Street 2:SUITE 305
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33150-2063
Practice Address - Country:US
Practice Address - Phone:305-694-9400
Practice Address - Fax:305-693-6942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91496207X00000X
FLME93941207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274429500Medicaid
FL271502300Medicaid
FLH94689Medicare UPIN
FLK8458Medicare PIN
FL271502300Medicaid