Provider Demographics
NPI:1851358345
Name:DERMATOLOGISTS OF ILLINOIS, PLLC
Entity type:Organization
Organization Name:DERMATOLOGISTS OF ILLINOIS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:KIRKLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-434-2351
Mailing Address - Street 1:5300 FAR HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2381
Mailing Address - Country:US
Mailing Address - Phone:937-436-4146
Mailing Address - Fax:937-530-4083
Practice Address - Street 1:225 E DEERPATH STE 50
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1970
Practice Address - Country:US
Practice Address - Phone:847-234-6121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036068947207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK10627Medicaid
ILK10628Medicaid
ILK10630Medicaid
ILK10629Medicaid
ILK10627Medicaid
ILK10629Medicaid
ILK10630Medicaid
ILC39596Medicare UPIN