MEDICARE: REVIVE PHYSICAL THERAPY LLC

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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1619827953
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVE PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	10300B BALTIMORE NATIONAL PIKE
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-2128
Country	:	US
Telephone Number	:	443-438-0586
Fax Number	:	443-364-3039

Provider Business Practice Location Address
First Line	:	10316A BALTIMORE NATIONAL PIKE
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-2128
Country	:	US
Telephone Number	:	443-438-0586
Fax Number	:	443-364-3039

Authorized Official
Title or Position	:	OWNER
Name	:	RENUKA JAIN
Credential	:	DPT
Telephone Number	:	781-266-6621

Provider Enumeration Date	:	01/28/2026
Last Update Date	:	01/28/2026

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