Healthcare Provider Details

I. General information

NPI: 1063030252
Provider Name (Legal Business Name): VITALSKIN MEDICAL GROUP IL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 REMINGTON RD
MATTOON IL
61938-4210
US

IV. Provider business mailing address

1111 W KENYON RD
URBANA IL
61801-1010
US

V. Phone/Fax

Practice location:
  • Phone: 217-205-3376
  • Fax:
Mailing address:
  • Phone: 415-802-1310
  • 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 Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: JEREMY SCOTT YOUSE
Title or Position: PHYSICIAN OWNER/CMO
Credential: MD
Phone: 415-802-1310