Provider Demographics
NPI:1225184948
Name:EDGEBROOK DERMATOLOGY P.C.
Entity Type:Organization
Organization Name:EDGEBROOK DERMATOLOGY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALBASHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-229-9333
Mailing Address - Street 1:PO BOX 1686
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61110-0186
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1639 N ALPINE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-1449
Practice Address - Country:US
Practice Address - Phone:815-229-9333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10107770OtherBLUE SHIELD
IL10107770OtherBLUE SHIELD