Provider Demographics
NPI:1700987328
Name:DERMATOLOGY AND PLASTIC SURGERY ASSOCIATES, S.C.
Entity Type:Organization
Organization Name:DERMATOLOGY AND PLASTIC SURGERY ASSOCIATES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V.P.
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:RIOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-744-8554
Mailing Address - Street 1:1124 ESSINGTON RD
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-8423
Mailing Address - Country:US
Mailing Address - Phone:815-744-8554
Mailing Address - Fax:815-744-3969
Practice Address - Street 1:1124 ESSINGTON RD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-8423
Practice Address - Country:US
Practice Address - Phone:815-744-8554
Practice Address - Fax:815-744-3969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036108932207NS0135X
IL036109103208200000X
IL085002224363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09932211OtherBC/BS GROUP NUMBER
IL09932211OtherBC/BS GROUP NUMBER