Healthcare Provider Details

I. General information

NPI: 1497930689
Provider Name (Legal Business Name): STROW DERMATOLOGY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2008
Last Update Date: 02/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2041 W ILES AVE
SPRINGFIELD IL
62704-7005
US

IV. Provider business mailing address

2041 W ILES AVE
SPRINGFIELD IL
62704-7005
US

V. Phone/Fax

Practice location:
  • Phone: 217-793-5517
  • Fax:
Mailing address:
  • Phone: 217-793-5517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number StateIL

VIII. Authorized Official

Name: M ELIZABETH STROW
Title or Position: MD
Credential:
Phone: 217-793-5517