Provider Demographics
NPI:1477617207
Name:WEST SUBURBAN DERMATOLOGY & COSMETIC SURGERY
Entity Type:Organization
Organization Name:WEST SUBURBAN DERMATOLOGY & COSMETIC SURGERY
Other - Org Name:CLEAR SKIN DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-443-8855
Mailing Address - Street 1:2560 FOXFIELD RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-5797
Mailing Address - Country:US
Mailing Address - Phone:630-443-8855
Mailing Address - Fax:630-443-8866
Practice Address - Street 1:2560 FOXFIELD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-5797
Practice Address - Country:US
Practice Address - Phone:630-443-8855
Practice Address - Fax:630-443-8866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036108686207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH83109Medicare UPIN