Healthcare Provider Details

I. General information

NPI: 1972283141
Provider Name (Legal Business Name): REVIVE ORTHOPEDICS SPINE & SPORTS SURGERY CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2023
Last Update Date: 07/21/2023
Certification Date: 07/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

939 BOB ARNOLD BLVD STE D
LITHIA SPRINGS GA
30122-3258
US

IV. Provider business mailing address

939 BOB ARNOLD BLVD STE A
LITHIA SPRINGS GA
30122-3258
US

V. Phone/Fax

Practice location:
  • Phone: 770-769-1724
  • Fax: 770-708-6599
Mailing address:
  • Phone: 770-769-1724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: SHEVIN D. POLLYDORE
Title or Position: CEO
Credential: MD
Phone: 770-769-1724