Basic Information
Provider Information
NPI: 1861930984
EntityType: 2
ReplacementNPI:  
OrganizationName: PINNACLE DERMATOLOGY, SC
LastName:  
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Mailing Information
Address1: 1124 ESSINGTON RD
Address2:  
City: JOLIET
State: IL
PostalCode: 604358423
CountryCode: US
TelephoneNumber: 8157448554
FaxNumber: 8157443969
Practice Location
Address1: 1124 ESSINGTON RD
Address2:  
City: JOLIET
State: IL
PostalCode: 604358423
CountryCode: US
TelephoneNumber: 8157448554
FaxNumber: 8157443969
Other Information
ProviderEnumerationDate: 02/09/2017
LastUpdateDate: 09/22/2021
NPIDeactivationReasonCode:  
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ProviderGenderCode:  
AuthorizedOfficialLastName: RIOS
AuthorizedOfficialFirstName: JOSE
AuthorizedOfficialMiddleName: L
AuthorizedOfficialTitleorPosition: VICE-PRESIDENT
AuthorizedOfficialTelephone: 6303889033
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MD
NPICertificationDate: 09/22/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
332900000X  N SuppliersNon-Pharmacy Dispensing Site 
332B00000X  N SuppliersDurable Medical Equipment & Medical Supplies 
208200000X036109103ILN193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPlastic Surgery 
207ND0101X036108932ILY193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery

No ID Information.


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