Provider Demographics
NPI:1922443340
Name:REVITALIZE MEDICAL GROUP, LTD
Entity Type:Organization
Organization Name:REVITALIZE MEDICAL GROUP, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE LEADER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-493-4443
Mailing Address - Street 1:4535 DRESSLER RD NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2545
Mailing Address - Country:US
Mailing Address - Phone:330-493-4443
Mailing Address - Fax:330-493-8677
Practice Address - Street 1:1 PARK WEST BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320-4218
Practice Address - Country:US
Practice Address - Phone:330-493-4443
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-30
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty