MEDICARE: RAVIVE PLASTIC SURGERY & MED SPA

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
1	208200000X	Plastic Surgery Physician

General Provider Information

NPI Number	:	1508631847
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RAVIVE PLASTIC SURGERY & MED SPA

Provider Business Mailing Address
First Line	:	2410 NORTHSIDE DR
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33761-2236
Country	:	US
Telephone Number	:	727-499-0351
Fax Number	:	727-223-4157

Provider Business Practice Location Address
First Line	:	3741 W NEPTUNE ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33629-5118
Country	:	US
Telephone Number	:	813-709-7511
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DEEPA BHAT
Credential	:	MD
Telephone Number	:	813-709-7511

Provider Enumeration Date	:	11/16/2023
Last Update Date	:	11/16/2023

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