Provider Demographics
NPI:1841900636
Name:REVIVE ORTHOPEDICS SPINE & SPORTS MEDICINE, INC
Entity type:Organization
Organization Name:REVIVE ORTHOPEDICS SPINE & SPORTS MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHEVIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:POLLYDORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-209-9913
Mailing Address - Street 1:3955 HARRISON RD STE 200B
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-8502
Mailing Address - Country:US
Mailing Address - Phone:770-209-9913
Mailing Address - Fax:678-902-8579
Practice Address - Street 1:3955 HARRISON RD STE 200B
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-8502
Practice Address - Country:US
Practice Address - Phone:770-209-9913
Practice Address - Fax:678-902-8579
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REVIVE ORTHOPEDICS SPINE & SPORTS MEDICINE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy