Provider Demographics
NPI:1891920898
Name:ILLINOIS DERMATOLOGY INSTITUTE, LLC
Entity Type:Organization
Organization Name:ILLINOIS DERMATOLOGY INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:LORBER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-675-9711
Mailing Address - Street 1:903 COMMERCE DRIVE
Mailing Address - Street 2:SUITE 333
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8723
Mailing Address - Country:US
Mailing Address - Phone:630-928-5224
Mailing Address - Fax:630-571-8810
Practice Address - Street 1:9711 SKOKIE BLVD
Practice Address - Street 2:SUITE J.
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1384
Practice Address - Country:US
Practice Address - Phone:847-675-9711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-19
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2485Medicare PIN
ILIL2486Medicare PIN