Healthcare Provider Details

I. General information

NPI: 1588283402
Provider Name (Legal Business Name): ILLINOIS SKIN CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2202 N HALSTED ST STE 1
CHICAGO IL
60614-3625
US

IV. Provider business mailing address

2202 N HALSTED ST STE 1
CHICAGO IL
60614-3625
US

V. Phone/Fax

Practice location:
  • Phone: 312-600-5826
  • Fax: 872-260-5008
Mailing address:
  • Phone: 312-600-5826
  • Fax: 872-260-5008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID OTHMAN
Title or Position: PRESIDENT AND CEO
Credential: MD
Phone: 312-600-5826