Healthcare Provider Details

I. General information

NPI: 1679158174
Provider Name (Legal Business Name): ASMSC-MORTON GROVE IL SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 WAUKEGAN RD
MORTON GROVE IL
60053-1312
US

IV. Provider business mailing address

2570 NILES RD
SAINT JOSEPH MI
49085-3203
US

V. Phone/Fax

Practice location:
  • Phone: 847-299-1044
  • Fax: 847-299-0425
Mailing address:
  • Phone: 269-985-0021
  • Fax: 269-281-0281

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 Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number
License Number State

VIII. Authorized Official

Name: CLARENCE W BROWN JR.
Title or Position: OWNER/CEO/PRESIDENT
Credential: M.D., J.D.
Phone: 269-985-0021