1639812811 NPI number — VITALSKIN MEDICAL GROUP IL PLLC

Table of content: AMY RACHELE GROSE BSP, MSCMHC, RMHCI (NPI 1780459081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639812811 NPI number — VITALSKIN MEDICAL GROUP IL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITALSKIN MEDICAL GROUP IL PLLC
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:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1639812811
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 W KENYON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
URBANA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61801-1010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-735-4059
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2857 CHARLESTOWN RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW ALBANY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47150-1998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-944-7500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/15/2022

Additional Information

Authorized Official

Authorized Official Last Name:
WIENS
Authorized Official First Name:
DAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
704-534-1854

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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