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General NPI Number Information
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NPI Number | 1306870233
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Entity Type | Organization
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Legal Business Name | SOUTHERN ILLINOIS DERMATOLOGY, PC
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Dates
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Enumeration Date | 07/10/2006
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Last Update Date | 07/29/2008
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Provider Practice Location Address
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Address Line | 220 N PARK AVE SUITE 2
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City | HERRIN
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State | IL
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Zip | 62948-3150
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Country | US
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Telephone | 618-942-3344
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Fax | 618-942-5045
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Provider Business Mailing Address
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Address Line | 220 N PARK AVE SUITE 2
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City | HERRIN
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State | IL
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Zip | 62948-3150
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Country | US
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Telephone | 618-942-3344
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Fax | 618-942-5045
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. TED G VAN ACKER
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Credential | D. O.
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Telephone | 618-942-3344
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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