Provider Demographics
NPI:1447613989
Name:ILLINOIS DERMATOLOGY INSTITUTE, LLC
Entity Type:Organization
Organization Name:ILLINOIS DERMATOLOGY INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANDREA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-298-1831
Mailing Address - Street 1:1550 N NORTHWEST HWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1411
Mailing Address - Country:US
Mailing Address - Phone:847-298-1831
Mailing Address - Fax:847-298-1832
Practice Address - Street 1:1550 N NORTHWEST HWY
Practice Address - Street 2:SUITE 300
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1411
Practice Address - Country:US
Practice Address - Phone:847-298-1831
Practice Address - Fax:847-298-1832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111710261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111710Medicaid
IL1386663631OtherNPI
IL036111710Medicaid