Provider Demographics
NPI:1356721591
Name:MOHS SURGERY &DERMATOLOGY
Entity type:Organization
Organization Name:MOHS SURGERY &DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-608-6647
Mailing Address - Street 1:1750 N RANDALL RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-7900
Mailing Address - Country:US
Mailing Address - Phone:847-608-6647
Mailing Address - Fax:
Practice Address - Street 1:1750 N RANDALL RD
Practice Address - Street 2:SUITE 120
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-7900
Practice Address - Country:US
Practice Address - Phone:847-608-6647
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.137205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty