MEDICARE: HEALTH REVIVAL MEDICAL PC

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	207Q00000X	Family Medicine Physician	223381	NY

General Provider Information

NPI Number	:	1093742900
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTH REVIVAL MEDICAL PC

Provider Business Mailing Address
First Line	:	21 GOODAL STREET
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	10308-3325
Country	:	US
Telephone Number	:	718-891-8822
Fax Number	:	718-891-8823

Provider Business Practice Location Address
First Line	:	HEALTH REVIVAL MEDICAL PC
Second Line	:	162 BRIGHTON STREET
City	:	BROOKLYN
State	:	NY
Zip	:	11235-5237
Country	:	US
Telephone Number	:	718-891-8822
Fax Number	:	718-891-8823

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	LARISA VEKSMAN
Credential	:	MD
Telephone Number	:	718-891-8822

Provider Enumeration Date	:	06/27/2006
Last Update Date	:	08/22/2020

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