1922260587 NPI number — MUSICK DERMATOLOGY & ADVANCED CLINICAL SPA, LLC

Table of content: (NPI 1922260587)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922260587 NPI number — MUSICK DERMATOLOGY & ADVANCED CLINICAL SPA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MUSICK DERMATOLOGY & ADVANCED CLINICAL SPA, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922260587
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4948 BENCHMARK CENTRE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SWANSEA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62226-2027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-628-2588
Provider Business Mailing Address Fax Number:
618-628-1363

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4948 BENCHMARK CENTRE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SWANSEA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62226-2027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-628-2588
Provider Business Practice Location Address Fax Number:
618-628-1363
Provider Enumeration Date:
06/25/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GLAUBER
Authorized Official First Name:
DORIS
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
618-628-2588

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  036089938 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com