| Revive Pcms Florida LLC | |
|
21859 State Road 54 Lutz FL 33549-6924 | |
| (813) 382-8747 | |
| (888) 355-6731 |
| Full Name | Revive Pcms Florida LLC |
|---|---|
| Speciality | Family Medicine |
| Location | 21859 State Road 54, Lutz, Florida |
| Authorized Official Name and Position | Zahid Jamal (OWNER) |
| Authorized Official Contact | 8134821688 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Revive Pcms Florida LLC 21859 State Road 54 Lutz FL 33549-6924 | Revive Pcms Florida LLC 21859 State Road 54 Lutz FL 33549-6924 Ph: (813) 382-8747 |
| NPI Number | 1386526978 |
|---|---|
| Provider Enumeration Date | 07/23/2025 |
| Last Update Date | 10/30/2025 |
| Certification Date | 10/30/2025 |
| Medicare PECOS PAC ID | 4880185552 |
|---|---|
| Medicare Enrollment ID | O20251111002474 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1386526978 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | () | Primary |
| Provider Name | Charles Talakkottur |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1598949034 PECOS PAC ID: 5092892281 Enrollment ID: I20080412000047 |
| Provider Name | Lindsay Mccullough |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1659197317 PECOS PAC ID: 6204358658 Enrollment ID: I20250314002996 |
| Provider Name | Kyle Kalra |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1568967909 PECOS PAC ID: 7719237346 Enrollment ID: I20251215000977 |
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