14D1052641 CLIA NUMBER - SOUTHERN ILLINOIS DERMATOLOGY

Laboratory Demographics

  • CLIA Code: 14D1052641
  • Facility Name: SOUTHERN ILLINOIS DERMATOLOGY
  • Facility Address: 300 SMALL STREET, SUITE 1
    HARRISBURG, IL
    ZIP 62946
  • Facility Phone: 618 942-3344
  • Facility Type: Physician Office
  • Facility Type: Microscopy
  • Lab Director: TED G. VAN ACKER
  • NPI Number: 1306870233
  • Taxonomy: 207N00000X - Dermatology

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CLIA Record

Field Name Field Value
CLIA Number 14D1052641
LAB Type Physician Office
Facility Name SOUTHERN ILLINOIS DERMATOLOGY
Street 300 SMALL STREET, SUITE 1
City HARRISBURG
State IL
ZIP 62946
Phone 618 942-3344
Certificate Type Certificate for Provider-Performed Microscopy Procedures (PPMP)
Certificate Type Description This certificate is issued to a laboratory in which a physician, midlevel practitioner or dentist performs no tests other than the microscopy procedures. This certificate permits the laboratory to also perform waived tests.
Certificate Effective Date 3/30/2024
Certificate Expiration Date 3/29/2026
Facility Type Physician Office
Lab Director TED G. VAN ACKER

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This page was last updated on: 9/29/2025