NPIMap

Organization Active NPI

Revive Orthopedics Spine & Sports Medicine, Inc

Doing business as Revive Orthopedics Spine & Sports Medicine

  • Orthopaedic Surgery Physician
  • Peachtree City, GA
National Provider Identifier
1285321091
Registry record updated Nov 22, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Orthopaedic Surgery PhysicianTaxonomy code 207X00000X
Legal business name
REVIVE ORTHOPEDICS SPINE & SPORTS MEDICINE, INC
Doing business as
Revive Orthopedics Spine & Sports Medicine
Practice address
3200 Shakerag HL Ste a
Peachtree City, GA 30269-6524
Phone
(770) 769-1724
Fax
(770) 708-6599
NPI assigned
Apr 20, 2023
Last updated
Nov 22, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 22, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Shevin Pollydore, MDNPI 1184616591
Title
Owner
Phone
(770) 769-1724

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Orthopaedic Surgery Physician 207X00000X NU Primary
Physical Medicine & Rehabilitation Physician 208100000X NU
Pain Medicine (Physical Medicine & Rehabilitation) Physician 2081P2900X NU
Pharmacy 333600000X NU

Addresses

Primary practice location

3200 Shakerag HL Ste a
Peachtree City, GA 30269-6524

Mailing address

939 Bob Arnold Blvd Ste a
Lithia Springs, GA 30122-3258
Phone (770) 769-1724

Other names 1

  • Revive Orthopedics Spine & Sports Medicine Doing business as

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
11D2339555Revive Orthopedics Spine & Sports Medicine3200 Shakerag Hill, Suite a, Peachtree City, GA 30269Certificate of waiverMar 3, 2028

National Provider Directory

National Provider Directory
Tax ID family
Revive Orthopedics Spine6 organizations share this tax ID, including this one

Other organizations with this tax ID 5

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1681948800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1700611200000",
    "number": "1285321091",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "939 BOB ARNOLD BLVD STE A",
            "city": "LITHIA SPRINGS",
            "state": "GA",
            "postal_code": "301223258",
            "telephone_number": "770-769-1724",
            "fax_number": "770-708-6599"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3200 SHAKERAG HL STE A",
            "city": "PEACHTREE CITY",
            "state": "GA",
            "postal_code": "302696524",
            "telephone_number": "770-769-1724",
            "fax_number": "770-708-6599"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REVIVE ORTHOPEDICS SPINE & SPORTS MEDICINE, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-04-20",
        "last_updated": "2023-11-22",
        "certification_date": "2023-11-22",
        "status": "A",
        "authorized_official_last_name": "POLLYDORE",
        "authorized_official_first_name": "SHEVIN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "770-769-1724",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207X00000X",
            "taxonomy_group": "",
            "desc": "Orthopaedic Surgery",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "208100000X",
            "taxonomy_group": "",
            "desc": "Physical Medicine & Rehabilitation",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2081P2900X",
            "taxonomy_group": "",
            "desc": "Physical Medicine & Rehabilitation, Pain Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Revive Orthopedics Spine & Sports Medicine",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Revive Orthopedics Spine & Sports Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Peachtree City, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 22, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.