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General NPI Number Information
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NPI Number | 1053362343
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Entity Type | Organization
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Legal Business Name | SODERSTROM DERMATOLOGY CENTER S C
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Dates
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Enumeration Date | 05/12/2006
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Last Update Date | 06/25/2008
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Provider Practice Location Address
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Address Line | 4909 N GLEN PARK PLACE RD
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City | PEORIA
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State | IL
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Zip | 61614-4676
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Country | US
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Telephone | 309-690-6012
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Fax |
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Provider Business Mailing Address
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Address Line | 4909 N GLEN PARK PLACE RD
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City | PEORIA
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State | IL
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Zip | 61614-4676
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Country | US
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Telephone | 309-690-6012
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR, SODERSTROM DERM
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Name | TINA M PEUGH
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Credential | MBA
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Telephone | 309-674-7546
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 7001530
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License Number State | IL
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