Provider Demographics
NPI:1407309560
Name:ST JOSEPH DERMATOLOGY AND VEIN CLINIC PLLC
Entity Type:Organization
Organization Name:ST JOSEPH DERMATOLOGY AND VEIN CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/ OWNER/ PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VASSILIOS
Authorized Official - Middle Name:ATHANASIOS
Authorized Official - Last Name:DIMITROPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-351-2862
Mailing Address - Street 1:745 S PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-4645
Mailing Address - Country:US
Mailing Address - Phone:773-351-2862
Mailing Address - Fax:773-358-2767
Practice Address - Street 1:2500 NILES RD STE 10A
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-3272
Practice Address - Country:US
Practice Address - Phone:773-351-2862
Practice Address - Fax:773-358-2767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-25
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079801207N00000X, 207ND0101X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1194838045Medicaid
ILI39241Medicare UPIN