REVIVE SKIN INSTITUTE LLC NPI 1104178144

NPI Information

  • NPI: 1104178144
  • Provider Name: REVIVE SKIN INSTITUTE LLC
  • Classification: Dermatology - 207NS0135X
  • Specialization: Procedural Dermatology
  • Entity Type: Organization
  • Doing Business As: DERMATOLOGY
  • Address: 1175 CEDAR CT
    CARBONDALE
    CARBONDALE, IL
    ZIP 62901
  • Phone: (619) 549-0300

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NPI Details

REVIVE SKIN INSTITUTE LLC is a procedural dermatology dermatology in Carbondale, IL. The provider is procedural Dermatology, a subspecialty of Dermatology, encompassing a wide variety of surgical procedures and methods to remove or modify skin tissue for health or cosmetic benefit. These methods include scalpel surgery, laser surgery, chemical surgery, cryosurgery (liquid nitrogen), electrosurgery, aspiration surgery, liposuction, injection of filler substances, and Mohs micrographic controlled surgery (a special technique for the removal of growths, especially skin cancers). REVIVE SKIN INSTITUTE LLC NPI is 1104178144. The provider is registered as an organization entity type and is a multi-specialty group.
The provider Is Doing Business As Dermatology.

The provider's business location address is:

1175 CEDAR CT
CARBONDALE
CARBONDALE, IL
ZIP 62901-333
Phone: (619) 549-0300

The provider's authorized official is Anup Kumar Chaudhry .
The authorized official title is Member and has the following contact phone number (618) 549-0300.

The enumeration date for this NPI number is 10/14/2012 and was last updated on 10/14/2012.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1207N00000XDermatology036094335ILLINOISNo
2207NS0135XDermatologyProcedural Dermatology036094335ILLINOISYes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
1036094335MEDICAIDILLINOIS
2C43899MEDICARE UPINILLINOIS

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 11/21/2025

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