Provider Demographics
NPI:1679158174
Name:ASMSC-MORTON GROVE IL SC
Entity type:Organization
Organization Name:ASMSC-MORTON GROVE IL SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:W
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD, JD
Authorized Official - Phone:269-985-0021
Mailing Address - Street 1:2570 NILES RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-3203
Mailing Address - Country:US
Mailing Address - Phone:269-985-0021
Mailing Address - Fax:269-281-0281
Practice Address - Street 1:9300 WAUKEGAN RD
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-1312
Practice Address - Country:US
Practice Address - Phone:847-299-1044
Practice Address - Fax:847-299-0425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Multi-Specialty