Healthcare Provider Details

I. General information

NPI: 1558006957
Provider Name (Legal Business Name): SYNERGY REVITALIZE MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2022
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5457 TWIN KNOLLS RD STE 300-S6
COLUMBIA MD
21045-3259
US

IV. Provider business mailing address

5457 TWIN KNOLLS RD STE 300-S11
COLUMBIA MD
21045-3259
US

V. Phone/Fax

Practice location:
  • Phone: 301-602-4658
  • Fax: 301-500-3114
Mailing address:
  • Phone: 301-602-4658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2081P0301X
TaxonomyBrain Injury Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ELAINE M TAYLOR
Title or Position: PRIMARY CARE PROVIDER
Credential:
Phone: 301-602-4658