MEDICARE: DERMATOLOGY CENTERS, SC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1437273083
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERMATOLOGY CENTERS, SC

Provider Business Mailing Address
First Line	:	738 W NORTHWEST HWY
Second Line	:
City	:	BARRINGTON
State	:	IL
Zip	:	60010-2640
Country	:	US
Telephone Number	:	847-382-5111
Fax Number	:

Provider Business Practice Location Address
First Line	:	183 HERITAGE DR
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-8042
Country	:	US
Telephone Number	:	815-455-4434
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID P VAN DAM
Credential	:	MD
Telephone Number	:	847-382-5111

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	10/22/2007

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