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General NPI Number Information
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NPI Number | 1942273974
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Entity Type | Organization
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Legal Business Name | DERMASSOCIATES LTD
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Dates
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Enumeration Date | 02/09/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3608 W MAIN ST
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City | BELLEVILLE
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State | IL
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Zip | 62226-6225
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Country | US
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Telephone | 618-397-6605
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Fax | 618-277-1251
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Provider Business Mailing Address
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Address Line | 3608 W MAIN ST
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City | BELLEVILLE
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State | IL
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Zip | 62226-6225
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Country | US
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Telephone | 618-397-6605
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Fax | 618-277-1251
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Authorized Official
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Title or Position | CEO/PHYSICIAN
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Name | DR. GARY JOHN VICIK
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Credential | M.D.
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Telephone | 618-397-6605
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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 | 36-49185
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License Number State | IL
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