Provider Demographics
NPI:1629765433
Name:REVIVE ORTHOPEDICS SPINE & SPORTS MEDICINE, INC
Entity Type:Organization
Organization Name:REVIVE ORTHOPEDICS SPINE & SPORTS MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHEVIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:POLLYDORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-769-1724
Mailing Address - Street 1:939 BOB ARNOLD BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-3258
Mailing Address - Country:US
Mailing Address - Phone:770-769-1724
Mailing Address - Fax:770-708-6599
Practice Address - Street 1:9905 N DAVIDSON PKWY STE 107
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-4200
Practice Address - Country:US
Practice Address - Phone:770-769-1724
Practice Address - Fax:770-708-6599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacyGroup - Multi-Specialty