Healthcare Provider Details

I. General information

NPI: 1851358345
Provider Name (Legal Business Name): DERMATOLOGISTS OF ILLINOIS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E DEERPATH STE 50
LAKE FOREST IL
60045-1970
US

IV. Provider business mailing address

5300 FAR HILLS AVE
DAYTON OH
45429-2381
US

V. Phone/Fax

Practice location:
  • Phone: 847-234-6121
  • Fax:
Mailing address:
  • Phone: 937-436-4146
  • Fax: 937-530-4083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036068947
License Number StateIL

VIII. Authorized Official

Name: DR. EUGENE BRENT KIRKLAND
Title or Position: OWNER
Credential: M.D.
Phone: 937-434-2351