Provider Demographics
NPI:1679695829
Name:DERMATOLOGY ASSOCIATES OF HINSDALE, S.C.
Entity type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF HINSDALE, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:O
Authorized Official - Last Name:ERTLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-325-6880
Mailing Address - Street 1:333 CHESTNUT ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3247
Mailing Address - Country:US
Mailing Address - Phone:630-325-6880
Mailing Address - Fax:630-325-5975
Practice Address - Street 1:333 CHESTNUT ST
Practice Address - Street 2:SUITE 202
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3247
Practice Address - Country:US
Practice Address - Phone:630-325-6880
Practice Address - Fax:630-325-5975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-043180207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1679695829OtherBCBSIL
IL1679695829OtherNPI GROUP
IL313480Medicare ID - Type Unspecified
ILC39542Medicare UPIN