Provider Demographics
NPI:1225081763
Name:DERMATOLOGY CENTER ASSOCIATES SC
Entity Type:Organization
Organization Name:DERMATOLOGY CENTER ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:B
Authorized Official - Last Name:BIELINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-636-3767
Mailing Address - Street 1:4647 W 103RD ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-4779
Mailing Address - Country:US
Mailing Address - Phone:708-636-3767
Mailing Address - Fax:708-636-4361
Practice Address - Street 1:4647 W 103RD ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-4779
Practice Address - Country:US
Practice Address - Phone:708-636-3767
Practice Address - Fax:708-636-4361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL341860Medicare ID - Type Unspecified