Healthcare Provider Details

I. General information

NPI: 1346832953
Provider Name (Legal Business Name): REVIVE MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2021
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 RAYMOND AVE STE 230
SAINT PAUL MN
55114-1503
US

IV. Provider business mailing address

7595 CURRELL BLVD UNIT 25404
WOODBURY MN
55125-2569
US

V. Phone/Fax

Practice location:
  • Phone: 651-746-4412
  • Fax:
Mailing address:
  • Phone: 612-730-5196
  • Fax: 651-647-1647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ALFONSO MORALES
Title or Position: OWNER
Credential: MD
Phone: 651-476-4412