14D2067838 CLIA NUMBER - SOUTHERN ILLINOIS DERMATOLOGY

Laboratory Demographics

  • CLIA Code: 14D2067838
  • Facility Name: SOUTHERN ILLINOIS DERMATOLOGY
  • Facility Address: 202 EAST 3RD
    CENTRALIA, IL
    ZIP 62801
  • Facility Phone: 618 532-6311
  • Facility Type: Physician Office
  • Facility Type: Microscopy
  • Lab Director: DEREK G. KENNEASTER M D
  • NPI Number: 1215243001
  • Taxonomy: 251B00000X - Case Management

Map and Directions

Get Directions

CLIA Record

Field Name Field Value
CLIA Number 14D2067838
LAB Type Physician Office
Facility Name SOUTHERN ILLINOIS DERMATOLOGY
Street 202 EAST 3RD
City CENTRALIA
State IL
ZIP 62801
Phone 618 532-6311
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 10/23/2025
Certificate Expiration Date 10/22/2027
Facility Type Physician Office
Lab Director DEREK G. KENNEASTER M D

Download Record

Download this CLIA record record in Text format: Export

Download this CLIA record record in Excel (CSV) format: Export

Download this CLIA record record in XML format: Export

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