Provider Demographics
NPI:1922053370
Name:PREMIER DERMATOLOGY LTD
Entity Type:Organization
Organization Name:PREMIER DERMATOLOGY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:R
Authorized Official - Last Name:KELLEHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-741-4343
Mailing Address - Street 1:2051 PLAINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CREST HILL
Mailing Address - State:IL
Mailing Address - Zip Code:60403-1865
Mailing Address - Country:US
Mailing Address - Phone:815-741-4343
Mailing Address - Fax:815-741-8660
Practice Address - Street 1:2051 PLAINFIELD RD
Practice Address - Street 2:
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60403-1865
Practice Address - Country:US
Practice Address - Phone:815-741-4343
Practice Address - Fax:815-741-8660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL009900257OtherBCBS OF IL PROVIDER #
IL572020Medicare ID - Type UnspecifiedPROVIDER NUMBER
IL009900257OtherBCBS OF IL PROVIDER #