Revived Medical Ipa LLC

Primary specialty

Psychiatry PhysicianTaxonomy code 2084P0800X

Legal business name

REVIVED MEDICAL IPA LLC

Practice address

1329 E 17TH St
Brooklyn, NY 11230-6052

Phone

(917) 584-1409

NPI assigned

May 19, 2022

Last updated

May 19, 2022By 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

Ilya Kiblitsky

Title

Sole Member

Phone

(917) 584-1409

Specialties & licenses 5

Addresses

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

{
    "created_epoch": "1652918400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1652918400000",
    "number": "1912644972",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1329 E 17TH ST",
            "city": "BROOKLYN",
            "state": "NY",
            "postal_code": "112306052"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1329 E 17TH ST",
            "city": "BROOKLYN",
            "state": "NY",
            "postal_code": "112306052",
            "telephone_number": "917-584-1409"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REVIVED MEDICAL IPA LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-05-19",
        "last_updated": "2022-05-19",
        "certification_date": "2022-05-19",
        "status": "A",
        "authorized_official_last_name": "KIBLITSKY",
        "authorized_official_first_name": "ILYA",
        "authorized_official_title_or_position": "SOLE MEMBER",
        "authorized_official_telephone_number": "917-584-1409"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "225X00000X",
            "taxonomy_group": "",
            "desc": "Occupational Therapist",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Psychiatry Physician in Brooklyn, NY
• Providers in Brooklyn, NY by specialty
• Psychiatry Physician in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 19, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.