Provider Demographics
NPI:1457985137
Name:REVIVE MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:REVIVE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CALVERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-501-6826
Mailing Address - Street 1:4312 S WOODBRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:NEW PALESTINE
Mailing Address - State:IN
Mailing Address - Zip Code:46163-9579
Mailing Address - Country:US
Mailing Address - Phone:317-501-6826
Mailing Address - Fax:
Practice Address - Street 1:7150 MADISON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-5269
Practice Address - Country:US
Practice Address - Phone:317-343-0334
Practice Address - Fax:317-348-3262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-03
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction MedicineGroup - Single Specialty
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty