Healthcare Provider Details

I. General information

NPI: 1407309560
Provider Name (Legal Business Name): ST JOSEPH DERMATOLOGY AND VEIN CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2016
Last Update Date: 01/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NILES RD STE 10A
SAINT JOSEPH MI
49085-3272
US

IV. Provider business mailing address

745 S PARK AVE
HINSDALE IL
60521-4645
US

V. Phone/Fax

Practice location:
  • Phone: 773-351-2862
  • Fax: 773-358-2767
Mailing address:
  • Phone: 773-351-2862
  • Fax: 773-358-2767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number4301079801
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number4301079801
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number4301079801
License Number StateMI

VIII. Authorized Official

Name: DR. VASSILIOS ATHANASIOS DIMITROPOULOS
Title or Position: PHYSICIAN/ OWNER/ PRESIDENT
Credential: M.D.
Phone: 773-351-2862