Healthcare Provider Details

I. General information

NPI: 1467955179
Provider Name (Legal Business Name): UNITED SKIN SPECIALISTS ILLINOIS LTD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4107 S WATER TOWER PL
MOUNT VERNON IL
62864-6293
US

IV. Provider business mailing address

2 CARLSON PKWY N STE 240
PLYMOUTH MN
55447-4485
US

V. Phone/Fax

Practice location:
  • Phone: 618-244-0031
  • Fax:
Mailing address:
  • Phone: 763-746-0030
  • Fax: 763-367-7977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: JIM FEINSTEIN
Title or Position: PRESEIDENT/COO
Credential:
Phone: 763-746-0030