Provider Demographics
NPI:1518028398
Name:DISTINCTIVE DERMATOLOGYLTD
Entity Type:Organization
Organization Name:DISTINCTIVE DERMATOLOGYLTD
Other - Org Name:GREGORY & ASSOCIATES DERMATOLOGY, LTD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOURNAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-233-7666
Mailing Address - Street 1:510 FULLERTON ROAD
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2970
Mailing Address - Country:US
Mailing Address - Phone:618-233-7666
Mailing Address - Fax:618-233-7461
Practice Address - Street 1:510 FULLERTON RD
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2970
Practice Address - Country:US
Practice Address - Phone:618-233-7666
Practice Address - Fax:618-233-7461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL8200530OtherBCBS GROUP LEGACY #
ILCA2289OtherMEDICARE RR GROUP PTAN
ILCA2289OtherMEDICARE RR GROUP PTAN