1548358054 NPI number — CENTRAL ILLINOIS DERMATOLOGY, S.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548358054 NPI number — CENTRAL ILLINOIS DERMATOLOGY, S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL ILLINOIS DERMATOLOGY, 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:
1548358054
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5401 N KNOXVILLE AVE
Provider Second Line Business Mailing Address:
SUITE 115
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61614-5095
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-691-2903
Provider Business Mailing Address Fax Number:
309-691-2909

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5401 N KNOXVILLE AVE
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61614-5095
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-691-2903
Provider Business Practice Location Address Fax Number:
309-691-2909
Provider Enumeration Date:
10/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KROODSMA
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
T
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
309-691-2903

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  042004157 , 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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