| Revive Medical Group, P.c. | |
|
1600 N 2nd St Clinton MO 64735-1192 | |
| (203) 430-1321 | |
| Not Available |
| Full Name | Revive Medical Group, P.c. |
|---|---|
| Speciality | Psychiatry & Neurology |
| Location | 1600 N 2nd St, Clinton, Missouri |
| Authorized Official Name and Position | Omar Ziyadeh (PC MANAGER) |
| Authorized Official Contact | 2034301321 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Revive Medical Group, P.c. 810 Reef Rd Fairfield CT 06824-6538 Ph: (203) 430-1321 | Revive Medical Group, P.c. 1600 N 2nd St Clinton MO 64735-1192 Ph: (203) 430-1321 |
| NPI Number | 1033798871 |
|---|---|
| Provider Enumeration Date | 04/07/2021 |
| Last Update Date | 04/13/2021 |
| Certification Date | 04/13/2021 |
| Medicare PECOS PAC ID | 8325447683 |
|---|---|
| Medicare Enrollment ID | O20210519000992 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1033798871 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2084P0800X | Psychiatry & Neurology - Psychiatry | (* (Not Available)) | Primary |
| Provider Name | Aneel Ursani |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1982085676 PECOS PAC ID: 3577863232 Enrollment ID: I20190816000088 |
| Provider Name | Satera N Washington |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1902248123 PECOS PAC ID: 3072886324 Enrollment ID: I20210616000878 |
| Provider Name | Michael Hall |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1609383082 PECOS PAC ID: 4082958772 Enrollment ID: I20210924002827 |
| Provider Name | Jessica E Campbell |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1598186801 PECOS PAC ID: 6800025784 Enrollment ID: I20210928003743 |
| Provider Name | Abiola Omo Oyemade |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1417454992 PECOS PAC ID: 6507102910 Enrollment ID: I20211011001594 |
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