Provider Demographics
NPI:1255358289
Name:CENTER FOR DERMATOLOGY AND SKIN CANCER LTD
Entity type:Organization
Organization Name:CENTER FOR DERMATOLOGY AND SKIN CANCER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:KOLBUSZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-964-2000
Mailing Address - Street 1:2500 S HIGHLAND AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-5363
Mailing Address - Country:US
Mailing Address - Phone:630-964-2000
Mailing Address - Fax:630-964-6378
Practice Address - Street 1:2500 S HIGHLAND AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-5363
Practice Address - Country:US
Practice Address - Phone:630-964-2000
Practice Address - Fax:630-964-6378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02207012OtherBCBS
214134Medicare ID - Type Unspecified