Healthcare Provider Details

I. General information

NPI: 1912195595
Provider Name (Legal Business Name): BABICH SKIN CARE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 10/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 W HAY ST SUITE 313
DECATUR IL
62526-6328
US

IV. Provider business mailing address

304 W HAY ST SUITE 313
DECATUR IL
62526-6328
US

V. Phone/Fax

Practice location:
  • Phone: 217-876-6890
  • Fax: 217-876-6895
Mailing address:
  • Phone: 217-876-6890
  • Fax: 217-876-6895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036-09961
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number036-099961
License Number StateIL

VIII. Authorized Official

Name: MR. SAMUEL BABICH
Title or Position: PRACTICE MANAGER
Credential:
Phone: 217-876-6890