NPIMap

Organization Active NPI

Revived Soul Medical PC

  • Psychiatry Physician
  • Brooklyn, NY
National Provider Identifier
1821389941
Registry record updated Apr 23, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
License
246958 Issued in NY
Legal business name
REVIVED SOUL MEDICAL PC
Practice address
1901 Avenue P
1A
Brooklyn, NY 11229-1342
Phone
(718) 382-5060
NPI assigned
Apr 23, 2011
Last updated
Apr 23, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 23, 2011

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

Authorized official

Name
Irina Kiblitsky, M.D.NPI 1215112719
Title
Owner
Phone
(718) 382-5060

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 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatry PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 2084P0800X 246958 NY Primary

Addresses

Primary practice location

1901 Avenue P
1A
Brooklyn, NY 11229-1342

Mailing address

1901 Avenue P
1A
Brooklyn, NY 11229-1342
Phone (718) 382-5060

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20110518000539 NY Part B Supplier - Clinic/Group Practice 0749466266 Receives reassigned benefits from 19 practitioners
Practice locations: Brooklyn, NY

National Provider Directory

National Provider Directory

Locations

307 Ocean View Ave
Brooklyn, NY 11235
Phone (718) 743-5555

Practitioners & affiliated clinicians

Practitioners 25

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.

View all 25

NPI Registry JSON

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

{
    "created_epoch": "1303516800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1303516800000",
    "number": "1821389941",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1901 AVENUE P",
            "address_2": "1A",
            "city": "BROOKLYN",
            "state": "NY",
            "postal_code": "112291342",
            "telephone_number": "718-382-5060"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1901 AVENUE P",
            "address_2": "1A",
            "city": "BROOKLYN",
            "state": "NY",
            "postal_code": "112291342",
            "telephone_number": "718-382-5060"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REVIVED SOUL MEDICAL PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-04-23",
        "last_updated": "2011-04-23",
        "status": "A",
        "authorized_official_last_name": "KIBLITSKY",
        "authorized_official_first_name": "IRINA",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "718-382-5060",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "2084P0800X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "NY",
            "license": "246958",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Brooklyn, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 23, 2011; 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.