Provider Demographics
NPI:1902933146
Name:ACADEMIC DERMATOLOGY & SKIN CANCER INSTITUTE, SC
Entity Type:Organization
Organization Name:ACADEMIC DERMATOLOGY & SKIN CANCER INSTITUTE, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANA
Authorized Official - Middle Name:
Authorized Official - Last Name:BALICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-230-0180
Mailing Address - Street 1:PO BOX 809397
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60680-9397
Mailing Address - Country:US
Mailing Address - Phone:312-230-0180
Mailing Address - Fax:312-230-0181
Practice Address - Street 1:50 E WASHINGTON ST STE 200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-2154
Practice Address - Country:US
Practice Address - Phone:312-230-0180
Practice Address - Fax:312-230-0181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042618008207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherTAX ID
IL201628Medicare UPIN
IL806507Medicare PIN