NPIMap

Organization Active NPI

Revive Orthopedics Spine & Sports Medicine, Inc

  • Multi-Specialty Clinic/Center
  • Lithia Springs, GA
National Provider Identifier
1306563663
Registry record updated Oct 26, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Multi-Specialty Clinic/CenterTaxonomy code 261QM1300X
Legal business name
REVIVE ORTHOPEDICS SPINE & SPORTS MEDICINE, INC
Practice address
939 Bob Arnold Blvd Ste a
Lithia Springs, GA 30122-3258
Phone
(770) 209-9913
Fax
(678) 902-8579
NPI assigned
Oct 26, 2022
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 26, 2022

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

Authorized official

Name
Shevin D Pollydore, MDNPI 1184616591
Title
Physician/Owner
Phone
(770) 209-9913

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Orthopaedic Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207X00000X
Sports Medicine (Orthopaedic Surgery) PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207XX0005X
Physical Medicine & Rehabilitation PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208100000X
Pain Medicine (Physical Medicine & Rehabilitation) PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2081P2900X
Multi-Specialty Clinic/Center 261QM1300X Primary

Addresses

Primary practice location

939 Bob Arnold Blvd Ste a
Lithia Springs, GA 30122-3258

Mailing address

939 Bob Arnold Blvd Ste a
Lithia Springs, GA 30122-3258
Phone (770) 209-9913

Other names 1

  • Revive Orthopedics Spine & Sports Medicine Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20240229000032 GA Part B Supplier - Clinic/Group Practice 6204271349 Receives reassigned benefits from 9 practitioners
Practice locations: Lithia Springs, GA; Loganville, GA; Peachtree City, GA; Roswell, GA; Stockbridge, GA

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
11D2327354Revive Orthopedics Spine & Sports Medicine939 Bob Arnold Road Blvd, Suite a, Lithia Springs, GA 30122Certificate of waiverJul 21, 2027

National Provider Directory

National Provider Directory
Tax ID family
Revive Orthopedics Spine Sports Medicine Inc6 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.

Locations

1750 Old Spring House Ln
Ste 205
Dunwoody, GA 30338
Phone (770) 451-4040

939 Bob Arnold Blvd
Ste A
Lithia Springs, GA 30122
Phone (770) 732-2959

939 Bob Arnold Blvd
Lithia Springs, GA 30122
Phone (770) 732-2959

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1666742400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1666742400000",
    "number": "1306563663",
    "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": "770-209-9913",
            "fax_number": "678-902-8579"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "939 BOB ARNOLD BLVD STE A",
            "city": "LITHIA SPRINGS",
            "state": "GA",
            "postal_code": "301223258",
            "telephone_number": "770-209-9913",
            "fax_number": "678-902-8579"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REVIVE ORTHOPEDICS SPINE & SPORTS MEDICINE, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-10-26",
        "last_updated": "2022-10-26",
        "certification_date": "2022-10-26",
        "status": "A",
        "authorized_official_last_name": "POLLYDORE",
        "authorized_official_first_name": "SHEVIN",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "PHYSICIAN/OWNER",
        "authorized_official_telephone_number": "770-209-9913",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207X00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Orthopaedic Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207XX0005X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Orthopaedic Surgery, Sports Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208100000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physical Medicine & Rehabilitation",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2081P2900X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physical Medicine & Rehabilitation, Pain Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Revive Orthopedics Spine & Sports Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lithia Springs, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 26, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • 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.