Provider Demographics
NPI:1689863904
Name:ASSOCIATES IN DERMATOLOGY SC
Entity Type:Organization
Organization Name:ASSOCIATES IN DERMATOLOGY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE BILLING ACCOUNTS PAYABLE
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORA
Authorized Official - Middle Name:F
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-662-8813
Mailing Address - Street 1:1404 EASTLAND DRIVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3532
Mailing Address - Country:US
Mailing Address - Phone:309-662-8813
Mailing Address - Fax:309-662-6835
Practice Address - Street 1:1404 EASTLAND DRIVE
Practice Address - Street 2:SUITE 204
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3532
Practice Address - Country:US
Practice Address - Phone:309-662-8813
Practice Address - Fax:309-662-6835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6170101Medicaid
IL=========6170101Medicaid