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NPI Code Detail

MEDICARE: RE VIVIFY MD HEALTH AND WELLNESS CENTER

MEDICARE: RE VIVIFY MD HEALTH AND WELLNESS CENTER
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207QA0505XAdult Medicine Physician
2207QG0300XGeriatric Medicine (Family Medicine) Physician
3207QP0002XPhysician Nutrition Specialist (Family Medicine)
4207QS0010XSports Medicine (Family Medicine) Physician
5207Q00000XFamily Medicine Physician

General Provider Information

NPI Number : 1023949617
Entity Type Code : Organization
Provider Name (Legal Business Name) : RE VIVIFY MD HEALTH AND WELLNESS CENTER
Provider Business Mailing Address
First Line : 898 OAK ST SW UNIT 3425
Second Line :
City : ATLANTA
State : GA
Zip : 30310-1974
Country : US
Telephone Number : 678-850-3509
Fax Number : 678-850-3509
Provider Business Practice Location Address
First Line : 898 OAK ST SW
Second Line :
City : ATLANTA
State : GA
Zip : 30310-1959
Country : US
Telephone Number : 678-850-3509
Fax Number : 678-850-3509
Authorized Official
Title or Position : FAMILY AND AESTHETIC MEDICINE
Name : NIJAH BURRIS
Credential : MD
Telephone Number : 678-850-3509
Provider Enumeration Date : 05/25/2026
Last Update Date : 05/25/2026

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Directions to “RE VIVIFY MD HEALTH AND WELLNESS CENTER ” Practice Location

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