Healthcare Provider Details

I. General information

NPI: 1841900636
Provider Name (Legal Business Name): REVIVE ORTHOPEDICS SPINE & SPORTS MEDICINE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2022
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3955 HARRISON RD STE 200B
LOGANVILLE GA
30052-8502
US

IV. Provider business mailing address

3955 HARRISON RD STE 200B
LOGANVILLE GA
30052-8502
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 Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

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