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General NPI Number Information
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NPI Number | 1588283402
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Entity Type | Organization
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Legal Business Name | ILLINOIS SKIN CENTER LLC
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Dates
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Enumeration Date | 04/10/2020
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Last Update Date | 02/27/2025
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Provider Practice Location Address
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Address Line | 2202 N HALSTED ST STE 1
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City | CHICAGO
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State | IL
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Zip | 60614-3625
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Country | US
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Telephone | 312-600-5826
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Fax | 872-260-5008
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Provider Business Mailing Address
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Address Line | 2202 N HALSTED ST STE 1
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City | CHICAGO
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State | IL
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Zip | 60614-3625
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Country | US
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Telephone | 312-600-5826
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Fax | 872-260-5008
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Authorized Official
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Title or Position | PRESIDENT AND CEO
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Name | DR. DAVID OTHMAN
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Credential | MD
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Telephone | 312-600-5826
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number |
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License Number State |
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Taxonomy #2
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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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