Provider Demographics
NPI:1932437290
Name:SURGICAL SERVICES OF ILLINOIS, SC
Entity Type:Organization
Organization Name:SURGICAL SERVICES OF ILLINOIS, SC
Other - Org Name:MD SKINCENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:I
Authorized Official - Last Name:JUN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-484-9900
Mailing Address - Street 1:1235 N MULFORD RD
Mailing Address - Street 2:STE. 205
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3879
Mailing Address - Country:US
Mailing Address - Phone:815-484-9900
Mailing Address - Fax:815-487-4949
Practice Address - Street 1:1235 N MULFORD RD
Practice Address - Street 2:STE. 205
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3879
Practice Address - Country:US
Practice Address - Phone:815-484-9900
Practice Address - Fax:815-487-4949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-25
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric OtolaryngologyGroup - Multi-Specialty
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Multi-Specialty
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & NeckGroup - Multi-Specialty
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic AllergyGroup - Multi-Specialty
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2884OtherMEDICARE ID
ILH48944Medicare UPIN