Healthcare Provider Details

I. General information

NPI: 1497576219
Provider Name (Legal Business Name): REVIVE GLOBAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5539 N MESA ST
EL PASO TX
79912-5422
US

IV. Provider business mailing address

5539 N MESA ST
EL PASO TX
79912-5422
US

V. Phone/Fax

Practice location:
  • Phone: 915-213-0900
  • Fax: 915-271-4145
Mailing address:
  • Phone: 915-213-0900
  • Fax: 915-271-4145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: FAHAD OMAR
Title or Position: PRESIDENT
Credential: MD
Phone: 915-213-0900