Provider Demographics
NPI:1558006957
Name:SYNERGY REVITALIZE MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:SYNERGY REVITALIZE MEDICAL CENTER, LLC
Other - Org Name:SYNERGY REVITALIZE MED & SPA CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-357-8977
Mailing Address - Street 1:5457 TWIN KNOLLS RD STE 300-S11
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-3259
Mailing Address - Country:US
Mailing Address - Phone:216-357-8977
Mailing Address - Fax:
Practice Address - Street 1:5457 TWIN KNOLLS RD STE 300-S11
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-3259
Practice Address - Country:US
Practice Address - Phone:216-357-8977
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-29
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD598055100Medicaid
MA1295045755OtherNPPES