=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891920898
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ILLINOIS DERMATOLOGY INSTITUTE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2009
-----------------------------------------------------
Last Update Date | 05/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9711 SKOKIE BLVD SUITE J.
-----------------------------------------------------
City | SKOKIE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60077-1384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-675-9711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 903 COMMERCE DR STE 302
-----------------------------------------------------
City | OAK BROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60523-8830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-769-3539
-----------------------------------------------------
Fax | 708-671-1378
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KEITH A. LOPATKA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 708-218-5874
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------