1558006957 NPI number — SYNERGY REVITALIZE MEDICAL CENTER, LLC

Table of content: (NPI 1558006957)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558006957 NPI number — SYNERGY REVITALIZE MEDICAL CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SYNERGY REVITALIZE MEDICAL CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558006957
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/10/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5457 TWIN KNOLLS RD STE 300-S11
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21045-3259
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-602-4658
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5457 TWIN KNOLLS RD STE 300-S6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21045-3259
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-602-4658
Provider Business Practice Location Address Fax Number:
301-500-3114
Provider Enumeration Date:
04/29/2022

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
ELAINE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRIMARY CARE PROVIDER
Authorized Official Telephone Number:
301-602-4658

Provider Taxonomy Codes

  • Taxonomy code: 207RG0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2081P0301X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1295045755 . This is a "NPPES" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 598055100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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