1962027581 NPI number — MICHIGAN CITY DERMATOLOGY AND VEIN CLINIC LLC

Table of content: (NPI 1962027581)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962027581 NPI number — MICHIGAN CITY DERMATOLOGY AND VEIN CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHIGAN CITY DERMATOLOGY AND VEIN CLINIC 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:
1962027581
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
745 S PARK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HINSDALE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60521-4645
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-351-2862
Provider Business Mailing Address Fax Number:
773-358-2767

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10282 W 400 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MICHIGAN CITY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46360-9470
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-351-2862
Provider Business Practice Location Address Fax Number:
773-358-2767
Provider Enumeration Date:
06/09/2020

Additional Information

Authorized Official

Authorized Official Last Name:
DIMITROPOULOS
Authorized Official First Name:
VASSILIOS
Authorized Official Middle Name:
ATHANASIOS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
773-351-2862

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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