Provider Demographics
NPI:1851358345
Name:DERMATOLOGISTS OF ILLINOIS, PLLC
Entity Type:Organization
Organization Name:DERMATOLOGISTS OF ILLINOIS, PLLC
Other - Org Name:THE SKIN CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:CONROY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-434-2351
Mailing Address - Street 1:900 N WESTMORELAND RD
Mailing Address - Street 2:SUITE 222
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1674
Mailing Address - Country:US
Mailing Address - Phone:847-234-6121
Mailing Address - Fax:847-482-0363
Practice Address - Street 1:900 N WESTMORELAND RD
Practice Address - Street 2:SUITE 222
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1674
Practice Address - Country:US
Practice Address - Phone:847-234-6121
Practice Address - Fax:847-482-0363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036068947207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK10627Medicaid
ILK10628Medicaid
ILK10630Medicaid
ILK10629Medicaid
ILK10627Medicaid
ILK10629Medicaid
ILK10630Medicaid
ILC39596Medicare UPIN