Provider Demographics
NPI:1558579243
Name:AFFILIATES IN DISEASES & SURGERY OF THE SKIN, S.C.
Entity Type:Organization
Organization Name:AFFILIATES IN DISEASES & SURGERY OF THE SKIN, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-383-6366
Mailing Address - Street 1:1050 CHICAGO AVENUE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302
Mailing Address - Country:US
Mailing Address - Phone:708-383-6366
Mailing Address - Fax:708-383-6449
Practice Address - Street 1:1050 CHICAGO AVENUE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302
Practice Address - Country:US
Practice Address - Phone:708-383-6366
Practice Address - Fax:708-383-6449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-052205261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL483231Medicare ID - Type Unspecified