Provider Demographics
NPI:1821389941
Name:REVIVED SOUL MEDICAL PC
Entity Type:Organization
Organization Name:REVIVED SOUL MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIBLITSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-382-5060
Mailing Address - Street 1:1901 AVENUE P
Mailing Address - Street 2:1A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1342
Mailing Address - Country:US
Mailing Address - Phone:718-382-5060
Mailing Address - Fax:
Practice Address - Street 1:1901 AVENUE P
Practice Address - Street 2:1A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1342
Practice Address - Country:US
Practice Address - Phone:718-382-5060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-23
Last Update Date:2011-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2469582084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty