Healthcare Provider Details

I. General information

NPI: 1306563663
Provider Name (Legal Business Name): REVIVE ORTHOPEDICS SPINE & SPORTS MEDICINE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

939 BOB ARNOLD BLVD STE A
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: 770-209-9913
  • Fax: 678-902-8579
Mailing address:
  • Phone: 770-209-9913
  • Fax: 678-902-8579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: SHEVIN D POLLYDORE
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 770-209-9913