Provider Demographics
NPI:1780795856
Name:DERMATOLOGY ASSOCIATES OF LAGRANGE SC
Entity type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF LAGRANGE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:HALPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-482-3213
Mailing Address - Street 1:5201 WILLOW SPRINGS RD
Mailing Address - Street 2:SUITE #430
Mailing Address - City:LA GRANGE HIGHLANDS
Mailing Address - State:IL
Mailing Address - Zip Code:60525-6537
Mailing Address - Country:US
Mailing Address - Phone:708-482-3213
Mailing Address - Fax:708-482-3230
Practice Address - Street 1:5201 WILLOW SPRINGS RD
Practice Address - Street 2:SUITE #430
Practice Address - City:LA GRANGE HIGHLANDS
Practice Address - State:IL
Practice Address - Zip Code:60525-6537
Practice Address - Country:US
Practice Address - Phone:708-482-3213
Practice Address - Fax:708-482-3230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042-616911207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty