Basic Information
| Provider Information | |||||||||
| NPI: | 1669599841 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SKIN CARE CENTER OF SOUTHERN IL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4107 S WATER TOWER PL | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628646293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182440031 | ||||||||
| FaxNumber: | 6182440056 | ||||||||
| Practice Location | |||||||||
| Address1: | 4107 S WATER TOWER PL | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628646293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182440031 | ||||||||
| FaxNumber: | 6182440056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2007 | ||||||||
| LastUpdateDate: | 06/25/2013 | ||||||||
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| AuthorizedOfficialLastName: | NAHASS | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6182440031 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0900X | 036094700 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology |
ID Information
| ID | Type | State | Issuer | Description | 152566974412 | 05 | IL | MEDICAID | CH5023 | 01 | IL | MEDICARE RAILROAD | OTHER |