Provider Demographics
NPI:1619271939
Name:DERMATOLOGY CARE CENTER, LTD.
Entity Type:Organization
Organization Name:DERMATOLOGY CARE CENTER, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:DOBBIN
Authorized Official - Last Name:CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-288-0998
Mailing Address - Street 1:22 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5669
Mailing Address - Country:US
Mailing Address - Phone:618-288-0998
Mailing Address - Fax:618-288-9934
Practice Address - Street 1:22 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5669
Practice Address - Country:US
Practice Address - Phone:618-288-0998
Practice Address - Fax:618-288-9934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-29
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036099452207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL419662147Medicaid
1992763353OtherNPI TYPE I
IL419662147Medicaid