Provider Demographics
NPI:1750801205
Name:REVIVE MEDICAL CENTER, LLC
Entity type:Organization
Organization Name:REVIVE MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:SCHULMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-545-8888
Mailing Address - Street 1:753 OLD NORCROSS RD STE A
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4312
Mailing Address - Country:US
Mailing Address - Phone:770-545-8888
Mailing Address - Fax:770-545-8889
Practice Address - Street 1:753 OLD NORCROSS RD STE A
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4312
Practice Address - Country:US
Practice Address - Phone:770-545-8888
Practice Address - Fax:770-545-8889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA111N00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty