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General NPI Number Information
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NPI Number | 1386769271
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Entity Type | Organization
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Legal Business Name | ELK GROVE DERMATOLOGY, S.C.
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Dates
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Enumeration Date | 03/20/2007
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Last Update Date | 10/25/2007
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Provider Practice Location Address
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Address Line | 901 BIESTERFIELD RD STE 209
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City | ELK GROVE VILLAGE
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State | IL
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Zip | 60007-7300
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Country | US
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Telephone | 847-593-6222
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Fax |
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Provider Business Mailing Address
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Address Line | 901 BIESTERFIELD RD STE 209
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City | ELK GROVE VILLAGE
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State | IL
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Zip | 60007-7300
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Country | US
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Telephone | 847-593-6222
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Fax |
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Authorized Official
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Title or Position | SOLE PROPIERTOR
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Name | DR. ROBERT B POLISKY
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Credential | M.D.
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Telephone | 847-593-6222
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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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