Provider Demographics
NPI:1417657321
Name:VITALSKIN MEDICAL GROUP IL PLLC
Entity Type:Organization
Organization Name:VITALSKIN MEDICAL GROUP IL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:YOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-729-7650
Mailing Address - Street 1:1111 W KENYON RD
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-1004
Mailing Address - Country:US
Mailing Address - Phone:217-729-7657
Mailing Address - Fax:
Practice Address - Street 1:1765 N ELSTON AVE STE 110
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-1501
Practice Address - Country:US
Practice Address - Phone:773-276-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty