Healthcare Provider Details

I. General information

NPI: 1194462382
Provider Name (Legal Business Name): FOREFRONT DERMATOLOGY, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2022
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 RICE LAKE SQ
WHEATON IL
60189-2136
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 630-221-1883
  • Fax: 630-221-1885
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

VIII. Authorized Official

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