Healthcare Provider Details

I. General information

NPI: 1093596652
Provider Name (Legal Business Name): DERMATOLOGY AND SKIN CANCER CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2023
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3302 GERIG DR STE 100
BLOOMINGTON IL
61704-6343
US

IV. Provider business mailing address

3302 GERIG DR STE 100
BLOOMINGTON IL
61704-6343
US

V. Phone/Fax

Practice location:
  • Phone: 309-533-7070
  • Fax: 855-710-6552
Mailing address:
  • Phone: 309-533-7070
  • Fax: 855-710-6552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: ADRIENNE SCHUPBACH
Title or Position: MD/PRACTICE OWNER
Credential: MD
Phone: 309-533-7070