Revitalize Spine & Sports Care PLLC

Primary specialty

Pain Medicine (Physical Medicine & Rehabilitation) PhysicianTaxonomy code 2081P2900X

Legal business name

REVITALIZE SPINE & SPORTS CARE PLLC

Practice address

4309 W 27TH PL Ste 202
Kennewick, WA 99338-2908

Phone

(509) 591-4966

NPI assigned

May 6, 2021

Last updated

May 6, 2021By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

John Groner, MDNPI 1184787491

Title

Owner / MD

Phone

(509) 591-4966

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in WA

Enrollment records 1

Locations

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.

• John B Groner, MD

  • Pain Medicine (Physical Medicine & Rehabilitation) Physician
  • Kennewick, WA
  • NPI 1184787491
  Medicare reassignment NPD Authorized official

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

{
    "created_epoch": "1620259200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1620259200000",
    "number": "1407430317",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4309 W 27TH PL STE 202",
            "city": "KENNEWICK",
            "state": "WA",
            "postal_code": "993382908"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4309 W 27TH PL STE 202",
            "city": "KENNEWICK",
            "state": "WA",
            "postal_code": "993382908",
            "telephone_number": "509-591-4966"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REVITALIZE SPINE & SPORTS CARE PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-05-06",
        "last_updated": "2021-05-06",
        "certification_date": "2021-05-06",
        "status": "A",
        "authorized_official_last_name": "GRONER",
        "authorized_official_first_name": "JOHN",
        "authorized_official_title_or_position": "OWNER / MD",
        "authorized_official_telephone_number": "509-591-4966",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "2081P2900X",
            "taxonomy_group": "",
            "desc": "Physical Medicine & Rehabilitation, Pain Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WA LICENSE",
            "identifier": "MD00049437",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Pain Medicine (Physical Medicine & Rehabilitation) Physician in Kennewick, WA
• Providers in Kennewick, WA by specialty
• Pain Medicine (Physical Medicine & Rehabilitation) Physician in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 6, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.