Provider Demographics
NPI:1841315884
Name:NORTHSHORE DERMATOLOGY CENTER SC
Entity type:Organization
Organization Name:NORTHSHORE DERMATOLOGY CENTER SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF NORTHSHORE DERMATOLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:TINA
Authorized Official - Middle Name:C
Authorized Official - Last Name:VENETOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-234-1177
Mailing Address - Street 1:925 SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044-2203
Mailing Address - Country:US
Mailing Address - Phone:847-234-1177
Mailing Address - Fax:847-234-1875
Practice Address - Street 1:925 SHERWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKE BLUFF
Practice Address - State:IL
Practice Address - Zip Code:60044-2203
Practice Address - Country:US
Practice Address - Phone:847-234-1177
Practice Address - Fax:847-234-1875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036084683207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01608107OtherBLUE CROSS BLUE SHIELD
IL393200Medicare PIN
IL01608107OtherBLUE CROSS BLUE SHIELD
ILG32656Medicare UPIN