Provider Demographics
NPI:1548358054
Name:CENTRAL ILLINOIS DERMATOLOGY, S.C.
Entity type:Organization
Organization Name:CENTRAL ILLINOIS DERMATOLOGY, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:T
Authorized Official - Last Name:KROODSMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-691-2903
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5095
Mailing Address - Country:US
Mailing Address - Phone:309-691-2903
Mailing Address - Fax:309-691-2909
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 115
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5095
Practice Address - Country:US
Practice Address - Phone:309-691-2903
Practice Address - Fax:309-691-2909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042004157207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty