Healthcare Provider Details

I. General information

NPI: 1790611838
Provider Name (Legal Business Name): REVIVE JOINT AND SPINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23902 FORD RD STE A
DEARBORN HEIGHTS MI
48127-3289
US

IV. Provider business mailing address

23902 FORD RD STE A
DEARBORN HEIGHTS MI
48127-3289
US

V. Phone/Fax

Practice location:
  • Phone: 313-777-7246
  • Fax: 313-672-6222
Mailing address:
  • Phone: 313-777-7246
  • Fax: 313-672-6222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MUSTAFA SHUKR
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 313-777-7246