1174984959 NPI number — ADVANCED SKIN AND MOHS SURGERY CENTER S.C.

Table of content: (NPI 1174984959)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174984959 NPI number — ADVANCED SKIN AND MOHS SURGERY CENTER S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED SKIN AND MOHS SURGERY CENTER S.C.
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:
1174984959
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2570 NILES RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT JOSEPH
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49085-3203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-985-0021
Provider Business Mailing Address Fax Number:
269-281-0281

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2845 N. SHERIDAN ROAD
Provider Second Line Business Practice Location Address:
STE 912
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60657
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-281-0046
Provider Business Practice Location Address Fax Number:
773-281-0228
Provider Enumeration Date:
03/08/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
CLARENCE
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
773-294-0107

Provider Taxonomy Codes

  • Taxonomy code: 207ND0101X , with the licence number:  036096380 , 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)





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