Provider Demographics
NPI:1093596652
Name:DERMATOLOGY AND SKIN CANCER CENTER
Entity Type:Organization
Organization Name:DERMATOLOGY AND SKIN CANCER CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADRIENNE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHUPBACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-533-7070
Mailing Address - Street 1:3302 GERIG DR STE 100
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-6343
Mailing Address - Country:US
Mailing Address - Phone:309-533-7070
Mailing Address - Fax:855-710-6552
Practice Address - Street 1:3302 GERIG DR STE 100
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-6343
Practice Address - Country:US
Practice Address - Phone:309-533-7070
Practice Address - Fax:855-710-6552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-10
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty