Provider Demographics
NPI:1588283402
Name:ILLINOIS SKIN CENTER LLC
Entity type:Organization
Organization Name:ILLINOIS SKIN CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:OTHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-600-5826
Mailing Address - Street 1:2202 N HALSTED ST STE 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-3625
Mailing Address - Country:US
Mailing Address - Phone:312-600-5826
Mailing Address - Fax:872-260-5008
Practice Address - Street 1:2202 N HALSTED ST STE 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3625
Practice Address - Country:US
Practice Address - Phone:312-600-5826
Practice Address - Fax:872-260-5008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-10
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty