MEDICARE: REVAMP - ENCARDIA, 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	:	1962245076
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVAMP - ENCARDIA, LLC

Provider Business Mailing Address
First Line	:	510 N BROAD ST STE 201
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19130-4379
Country	:	US
Telephone Number	:	267-908-9520
Fax Number	:

Provider Business Practice Location Address
First Line	:	510 N BROAD ST STE 201
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19130-4379
Country	:	US
Telephone Number	:	267-908-9520
Fax Number	:

Authorized Official
Title or Position	:	OFFICER AND AUTHORIZED OFFICIAL
Name	:	JENNIFER BOYD BALDOCK
Credential	:
Telephone Number	:	615-234-5954

Provider Enumeration Date	:	06/17/2024
Last Update Date	:	01/08/2026

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