Provider Demographics
NPI:1336396563
Name:ADULT & PEDIATRIC DERMATOLOGY OF NAPERVILLE, LTD.
Entity Type:Organization
Organization Name:ADULT & PEDIATRIC DERMATOLOGY OF NAPERVILLE, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.O.
Authorized Official - Prefix:DR
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KEEGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-369-3376
Mailing Address - Street 1:120 SPALDING DR
Mailing Address - Street 2:SUITE 401
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-6508
Mailing Address - Country:US
Mailing Address - Phone:630-369-3376
Mailing Address - Fax:630-369-8838
Practice Address - Street 1:120 SPALDING DR
Practice Address - Street 2:SUITE 401
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6508
Practice Address - Country:US
Practice Address - Phone:630-369-3376
Practice Address - Fax:630-369-8838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-076923207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE66905Medicare UPIN