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NPI Code Detail

MEDICARE: VITALSKIN MEDICAL GROUP IL PLLC

MEDICARE: VITALSKIN MEDICAL GROUP IL PLLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207N00000XDermatology Physician

General Provider Information

NPI Number : 1639812811
Entity Type Code : Organization
Provider Name (Legal Business Name) : VITALSKIN MEDICAL GROUP IL PLLC
Provider Business Mailing Address
First Line : 1111 W KENYON RD
Second Line :
City : URBANA
State : IL
Zip : 61801-1010
Country : US
Telephone Number : 858-735-4059
Fax Number :
Provider Business Practice Location Address
First Line : 2857 CHARLESTOWN RD STE 100
Second Line :
City : NEW ALBANY
State : IN
Zip : 47150-1998
Country : US
Telephone Number : 812-944-7500
Fax Number :
Authorized Official
Title or Position : CHIEF FINANCIAL OFFICER
Name : DAN WIENS
Credential :
Telephone Number : 704-534-1854
Provider Enumeration Date : 04/15/2022
Last Update Date : 08/12/2024

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Directions to “VITALSKIN MEDICAL GROUP IL PLLC ” Practice Location

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