Provider Demographics
NPI:1881384915
Name:VITALSKIN MEDICAL GROUP IL PLLC
Entity type:Organization
Organization Name:VITALSKIN MEDICAL GROUP IL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:YOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-729-7650
Mailing Address - Street 1:1111 W KENYON RD STE B
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-1006
Mailing Address - Country:US
Mailing Address - Phone:217-729-7650
Mailing Address - Fax:
Practice Address - Street 1:621 S NEW BALLAS RD STE 5002B
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8270
Practice Address - Country:US
Practice Address - Phone:314-432-3033
Practice Address - Fax:314-995-9985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty