Provider Demographics
NPI:1922179787
Name:REVIVO, GADI ASHER (DO)
Entity Type:Individual
Prefix:
First Name:GADI
Middle Name:ASHER
Last Name:REVIVO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 E ERIE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3167
Mailing Address - Country:US
Mailing Address - Phone:312-238-1000
Mailing Address - Fax:
Practice Address - Street 1:355 E ERIE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3167
Practice Address - Country:US
Practice Address - Phone:312-238-1000
Practice Address - Fax:312-238-1208
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-104471208100000X, 2081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036104471-1Medicaid
IL036104471-2Medicaid
IL036104471-1Medicaid
ILL86925Medicare PIN
IL036104471-1Medicaid
CAW20A8249AMedicare ID - Type Unspecified
ILL86922Medicare PIN
ILL88134Medicare PIN