Healthcare Provider Details

I. General information

NPI: 1306870233
Provider Name (Legal Business Name): SOUTHERN ILLINOIS DERMATOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 N PARK AVE SUITE 2
HERRIN IL
62948-3150
US

IV. Provider business mailing address

220 N PARK AVE SUITE 2
HERRIN IL
62948-3150
US

V. Phone/Fax

Practice location:
  • Phone: 618-942-3344
  • Fax: 618-942-5045
Mailing address:
  • Phone: 618-942-3344
  • Fax: 618-942-5045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TED G VAN ACKER
Title or Position: PRESIDENT
Credential: D. O.
Phone: 618-942-3344