Provider Demographics
NPI:1144610080
Name:DERMATOLOGY SPECIALISTS OF ILLINOIS, LTD
Entity Type:Organization
Organization Name:DERMATOLOGY SPECIALISTS OF ILLINOIS, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VIKRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KHANNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-528-1177
Mailing Address - Street 1:2430 ESPLANADE DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2430 ESPLANADE DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102
Practice Address - Country:US
Practice Address - Phone:212-627-6515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-30
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1093219610Medicaid