Healthcare Provider Details

I. General information

NPI: 1396484119
Provider Name (Legal Business Name): ON THE SPOT DERMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2022
Last Update Date: 08/17/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3633 W LAKE AVE STE 409
GLENVIEW IL
60026-5804
US

IV. Provider business mailing address

2175 WOODLAWN RD
NORTHBROOK IL
60062-6072
US

V. Phone/Fax

Practice location:
  • Phone: 847-208-1016
  • Fax:
Mailing address:
  • Phone: 847-208-1016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. PAIGE LEPP
Title or Position: PRESIDENT
Credential: FNP-BC, FPA
Phone: 847-208-1016