Basic Information
| Provider Information | |||||||||
| NPI: | 1891920898 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ILLINOIS DERMATOLOGY INSTITUTE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 903 COMMERCE DRIVE | ||||||||
| Address2: | SUITE 333 | ||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605238723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309285224 | ||||||||
| FaxNumber: | 6305718810 | ||||||||
| Practice Location | |||||||||
| Address1: | 9711 SKOKIE BLVD | ||||||||
| Address2: | SUITE J. | ||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600771384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476759711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2009 | ||||||||
| LastUpdateDate: | 03/08/2010 | ||||||||
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| AuthorizedOfficialLastName: | LORBER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8476759711 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.