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General NPI Number Information
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NPI Number | 1770828626
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Entity Type | Organization
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Legal Business Name | DERMATOLOGY AND MOHS SURGERY INSTITUTE, LTD.
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Dates
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Enumeration Date | 12/04/2012
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Last Update Date | 01/29/2013
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Provider Practice Location Address
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Address Line | 3024 E EMPIRE ST 2ND FLOOR, SUITE F
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City | BLOOMINGTON
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State | IL
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Zip | 61704-5402
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Country | US
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Telephone | 309-678-9596
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Fax |
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Provider Business Mailing Address
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Address Line | 3024 E EMPIRE ST 2ND FLOOR, SUITE F
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City | BLOOMINGTON
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State | IL
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Zip | 61704-5402
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Country | US
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Telephone | 309-678-9596
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. DOUGLAS M LEONE
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Credential | M.D.
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Telephone | 309-678-9596
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 036.129240
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License Number State | IL
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