Provider Demographics
NPI:1477297083
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 FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WIENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-534-1854
Mailing Address - Street 1:1111 W KENYON RD
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-1010
Mailing Address - Country:US
Mailing Address - Phone:858-735-4059
Mailing Address - Fax:
Practice Address - Street 1:7931 BARDSTOWN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-3437
Practice Address - Country:US
Practice Address - Phone:502-349-9999
Practice Address - Fax:502-349-9499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-21
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty