Provider Demographics
NPI:1457896003
Name:REVIVE SPINE AND PAIN CENTER
Entity Type:Organization
Organization Name:REVIVE SPINE AND PAIN CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RIZKALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-983-9001
Mailing Address - Street 1:PO BOX 1126
Mailing Address - Street 2:
Mailing Address - City:ABSECON
Mailing Address - State:NJ
Mailing Address - Zip Code:08201
Mailing Address - Country:US
Mailing Address - Phone:856-983-9001
Mailing Address - Fax:
Practice Address - Street 1:1001 LINCOLN DR W STE E
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-1534
Practice Address - Country:US
Practice Address - Phone:856-983-9001
Practice Address - Fax:856-983-9011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-05
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2081S0010X
NJ25MA08922900261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPainGroup - Single Specialty