MEDICARE: REVIVE SURGICENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1023816774
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVE SURGICENTER LLC

Provider Business Mailing Address
First Line	:	1347 E SAMPLE RD STE 102
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33064-6278
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1347 E SAMPLE RD STE 102
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33064-6278
Country	:	US
Telephone Number	:	314-283-8738
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DANE POHLMAN
Credential	:	DO
Telephone Number	:	314-283-8738

Provider Enumeration Date	:	03/06/2025
Last Update Date	:	03/06/2025

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