Basic Information
Provider Information | |||||||||
NPI: | 1194225268 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNITED SKIN SPECIALISTS ILLINOIS LTD, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2 CARLSON PKWY N STE 240 | ||||||||
Address2: |   | ||||||||
City: | PLYMOUTH | ||||||||
State: | MN | ||||||||
PostalCode: | 554474485 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7637460030 | ||||||||
FaxNumber: | 7633673677 | ||||||||
Practice Location | |||||||||
Address1: | 4107 S WATER TOWER PL | ||||||||
Address2: |   | ||||||||
City: | MOUNT VERNON | ||||||||
State: | IL | ||||||||
PostalCode: | 628646293 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6182440031 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/15/2018 | ||||||||
LastUpdateDate: | 09/06/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROGERS | ||||||||
AuthorizedOfficialFirstName: | CATHERINE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
AuthorizedOfficialTelephone: | 7633677110 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/06/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0900X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207N00000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |   |
No ID Information.