Healthcare Provider Details

I. General information

NPI: 1801813712
Provider Name (Legal Business Name): REVIVAL PAIN MANAGEMENT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 N BRIDGE ST STE 101
ELKIN NC
28621-2105
US

IV. Provider business mailing address

1925 N BRIDGE ST STE 101
ELKIN NC
28621-2105
US

V. Phone/Fax

Practice location:
  • Phone: 336-835-5330
  • Fax: 336-835-5337
Mailing address:
  • Phone: 336-835-5330
  • Fax: 336-835-5337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: EMIDIO MICHAEL NOVEMBRE
Title or Position: PRACTICE OWNER
Credential: DO
Phone: 336-835-5330