Provider Demographics
NPI:1962027581
Name:MICHIGAN CITY DERMATOLOGY AND VEIN CLINIC LLC
Entity Type:Organization
Organization Name:MICHIGAN CITY DERMATOLOGY AND VEIN CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VASSILIOS
Authorized Official - Middle Name:ATHANASIOS
Authorized Official - Last Name:DIMITROPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-351-2862
Mailing Address - Street 1:745 S PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-4645
Mailing Address - Country:US
Mailing Address - Phone:773-351-2862
Mailing Address - Fax:773-358-2767
Practice Address - Street 1:10282 W 400 N
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-9470
Practice Address - Country:US
Practice Address - Phone:773-351-2862
Practice Address - Fax:773-358-2767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty