Healthcare Provider Details

I. General information

NPI: 1710931670
Provider Name (Legal Business Name): SODERSTROM DERMATOLOGY CENTER S C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4909 N GLEN PARK PLACE RD
PEORIA IL
61614-4676
US

IV. Provider business mailing address

4909 N GLEN PARK PLACE RD
PEORIA IL
61614-4676
US

V. Phone/Fax

Practice location:
  • Phone: 309-674-7546
  • Fax:
Mailing address:
  • Phone: 309-674-7546
  • 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 Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. CHRISTINA M PEUGH
Title or Position: EXECUTIVE DIRECTOR
Credential: MBA
Phone: 309-674-7546