Provider Demographics
NPI:1942671060
Name:REVOLUTION HEALTH MEDICAL CENTER
Entity Type:Organization
Organization Name:REVOLUTION HEALTH MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:NMD
Authorized Official - Phone:602-265-1774
Mailing Address - Street 1:1641 E OSBORN RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7146
Mailing Address - Country:US
Mailing Address - Phone:602-265-1774
Mailing Address - Fax:602-265-1738
Practice Address - Street 1:1641 E OSBORN RD
Practice Address - Street 2:SUITE 6
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7146
Practice Address - Country:US
Practice Address - Phone:602-265-1774
Practice Address - Fax:602-265-1738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15-1501261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center