Healthcare Provider Details

I. General information

NPI: 1023420361
Provider Name (Legal Business Name): ELISE SCOGGIN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2014
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 MAINE ST
QUINCY IL
62305-5875
US

IV. Provider business mailing address

1005 BROADWAY ST
QUINCY IL
62301-2834
US

V. Phone/Fax

Practice location:
  • Phone: 217-214-6250
  • Fax: 217-214-5826
Mailing address:
  • Phone: 217-223-1200
  • Fax: 217-277-3960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number036146947
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036146947
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberOT015672
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: