Provider Demographics
NPI:1053362343
Name:SODERSTROM DERMATOLOGY CENTER S C
Entity type:Organization
Organization Name:SODERSTROM DERMATOLOGY CENTER S C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR, SODERSTROM DERM
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PEUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:309-674-7546
Mailing Address - Street 1:4909 N GLEN PARK PLACE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4676
Mailing Address - Country:US
Mailing Address - Phone:309-690-6012
Mailing Address - Fax:
Practice Address - Street 1:4909 N GLEN PARK PLACE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4676
Practice Address - Country:US
Practice Address - Phone:309-690-6012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SODERSTROM DERMATOLOGY CENTER S C
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-12
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7001530261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL141058Medicare PIN