Healthcare Provider Details

I. General information

NPI: 1053994004
Provider Name (Legal Business Name): FOREFRONT DERMATOLOGY, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2604 DEMPSTER ST STE 101
PARK RIDGE IL
60068-8425
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 847-843-3376
  • Fax: 847-998-8631
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DENISE L ANGER
Title or Position: SR. DIRECTOR, PROVIDER ENROLLMENT
Credential:
Phone: 920-663-9022