Healthcare Provider Details

I. General information

NPI: 1245887959
Provider Name (Legal Business Name): REVOLUTION MEDICINE HEALTH & FITNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2019
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 CONNECTICUT AVE NW STE 500
WASHINGTON DC
20036-5304
US

IV. Provider business mailing address

1050 CONNECTICUT AVE NW STE 500
WASHINGTON DC
20036-5304
US

V. Phone/Fax

Practice location:
  • Phone: 202-596-8891
  • Fax: 304-245-6029
Mailing address:
  • Phone: 202-596-8891
  • Fax: 304-245-6029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL L GLICKMAN
Title or Position: PHYSICIAN
Credential: MD
Phone: 202-596-8891