Revive Skin Institute LLC

Primary specialty

Procedural Dermatology PhysicianTaxonomy code 207NS0135X

License

036094335 Issued in IL

Legal business name

REVIVE SKIN INSTITUTE LLC

Practice address

1175 Cedar CT
Carbondale
Carbondale, IL 62901-5333

Phone

(619) 549-0300

NPI assigned

Oct 14, 2012

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Anup Kumar Chaudhry, M.D.

Title

Member

Phone

(618) 549-0300

Specialties & licenses 2

Addresses

Other identifiers 1

Other names 1

• Dermatology Doing business as

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Mukesh Chaudhry, M.D.

  • Family Medicine Physician
  • Carbondale, IL
  • NPI 1508866559
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1350172800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1350172800000",
    "number": "1104178144",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1175 CEDAR CT",
            "address_2": "CARBONDALE",
            "city": "CARBONDALE",
            "state": "IL",
            "postal_code": "629015333",
            "telephone_number": "619-549-0300"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1175 CEDAR CT",
            "address_2": "CARBONDALE",
            "city": "CARBONDALE",
            "state": "IL",
            "postal_code": "629015333",
            "telephone_number": "619-549-0300"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REVIVE SKIN INSTITUTE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-10-14",
        "last_updated": "2012-10-14",
        "status": "A",
        "authorized_official_last_name": "CHAUDHRY",
        "authorized_official_first_name": "ANUP",
        "authorized_official_middle_name": "KUMAR",
        "authorized_official_title_or_position": "MEMBER",
        "authorized_official_telephone_number": "618-549-0300",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology",
            "state": "IL",
            "license": "036094335",
            "primary": false
        },
        {
            "code": "207NS0135X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology, Procedural Dermatology",
            "state": "IL",
            "license": "036094335",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036094335",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Dermatology",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Mary Reeder, RDH
• Rehab Innovations LLC
• Jessica Nicole Reichert, CNM
• Jennifer Reliford
• Rebecca Elizabeth Renfroe, NP
• Rhiannon Kuruppu, DMD LLC
• Rhonda Rhodes, PTA
• Arbaz Syed Riaz, MD
• Rachel Rice, LCSW
• Taylor Rice, CRNA

• Procedural Dermatology Physician in Carbondale, IL
• Providers in Carbondale, IL by specialty
• Procedural Dermatology Physician in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 14, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.