1245716042 NPI number — BASKO DERMATOLOGY LLC

Table of content: (NPI 1245716042)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245716042 NPI number — BASKO DERMATOLOGY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BASKO DERMATOLOGY 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:
1245716042
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1331 W 75TH ST STE 402
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAPERVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60540-9311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-596-8045
Provider Business Mailing Address Fax Number:
630-590-9634

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1331 W 75TH ST STE 402
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAPERVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60540-9336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-596-8045
Provider Business Practice Location Address Fax Number:
630-590-9634
Provider Enumeration Date:
07/14/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BASKO-PLLUSKA
Authorized Official First Name:
JULIANA
Authorized Official Middle Name:
LLAZAR
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
773-988-5833

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  036.132089 , 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)