Healthcare Provider Details

I. General information

NPI: 1629260039
Provider Name (Legal Business Name): COSMETIC DERMATOLOGY&SURGERYPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2007
Last Update Date: 09/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 LINCOLN HWY
OLYMPIA FIELDS IL
60461-1846
US

IV. Provider business mailing address

2605 LINCOLN HWY
OLYMPIA FIELDS IL
60461-1846
US

V. Phone/Fax

Practice location:
  • Phone: 708-481-9370
  • Fax: 708-481-9369
Mailing address:
  • Phone: 708-481-9370
  • Fax: 708-481-9369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. VLADIMIR V PANINE
Title or Position: OWNER
Credential: MD.
Phone: 708-481-9370