Organization
REVIVE SKIN INSTITUTE LLC
Active
Other names
Dermatology
Organization subpart
No
Provider details
NPI number
Authorized official
DR. ANUP KUMAR CHAUDHRY M.D. (MEMBER)
(618) 549-0300
Entity
Organization
Contact information
Practice address
1175 CEDAR CT, CARBONDALE, CARBONDALE, IL 62901-5333
(619) 549-0300
Mailing address
1175 CEDAR CT, CARBONDALE, CARBONDALE, IL 62901-5333
(619) 549-0300
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
036094335
IL
207NS0135X
Procedural Dermatology Physician
Primary
036094335
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036094335
—
IL
Enumeration date
10/14/2012
Last updated
10/14/2012
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