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General NPI Number Information
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NPI Number | 1104178144
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Entity Type | Organization
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Legal Business Name | REVIVE SKIN INSTITUTE LLC
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Dates
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Enumeration Date | 10/14/2012
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Last Update Date | 10/14/2012
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Provider Practice Location Address
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Address Line | 1175 CEDAR CT CARBONDALE
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City | CARBONDALE
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State | IL
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Zip | 62901-5333
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Country | US
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Telephone | 619-549-0300
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Fax |
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Provider Business Mailing Address
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Address Line | 1175 CEDAR CT CARBONDALE
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City | CARBONDALE
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State | IL
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Zip | 62901-5333
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Country | US
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Telephone | 619-549-0300
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | DR. ANUP KUMAR CHAUDHRY
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Credential | M.D.
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Telephone | 618-549-0300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 036094335
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 207NS0135X
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Taxonomy Name | Procedural Dermatology Physician
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License Number | 036094335
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License Number State | IL
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