Healthcare Provider Details

I. General information

NPI: 1033798871
Provider Name (Legal Business Name): REVIVE MEDICAL GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2021
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 N 2ND ST
CLINTON MO
64735-1192
US

IV. Provider business mailing address

810 REEF RD
FAIRFIELD CT
06824-6538
US

V. Phone/Fax

Practice location:
  • Phone: 203-430-1321
  • Fax:
Mailing address:
  • Phone: 203-430-1321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: OMAR ZIYADEH
Title or Position: PC MANAGER
Credential:
Phone: 203-430-1321