Provider Demographics
NPI:1982777231
Name:CRYSTAL LAKE DERMATOLOGY SC
Entity Type:Organization
Organization Name:CRYSTAL LAKE DERMATOLOGY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:SO-YUNG
Authorized Official - Last Name:CHIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-477-9858
Mailing Address - Street 1:278 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014
Mailing Address - Country:US
Mailing Address - Phone:815-477-9867
Mailing Address - Fax:815-477-9868
Practice Address - Street 1:278 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014
Practice Address - Country:US
Practice Address - Phone:815-477-9867
Practice Address - Fax:815-477-9868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL526860Medicare PIN
ILCF8046Medicare PIN