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SODERSTROM DERMATOLOGY CENTER S C NPI 1710931670


NPI Information

NPI: 1710931670
Provider Name: SODERSTROM DERMATOLOGY CENTER S C
Classification: Dermatology - 207N00000X
Entity Type: Organization

CLIA Number: 14D0648270

Address:
4909 N GLEN PARK PLACE RD
PEORIA, IL
ZIP 61614
Phone: (309) 674-7546
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SODERSTROM DERMATOLOGY CENTER S C is a dermatology in Peoria, IL. The provider is a dermatologist is trained to diagnose and treat pediatric and adult patients with benign and malignant disorders of the skin, mouth, external genitalia, hair and nails, as well as a number of sexually transmitted diseases. The dermatologist has had additional training and experience in the diagnosis and treatment of skin cancers, melanomas, moles and other tumors of the skin, the management of contact dermatitis and other allergic and nonallergic skin disorders, and in the recognition of the skin manifestations of systemic (including internal malignancy) and infectious diseases. Dermatologists have special training in dermatopathology and in the surgical techniques used in dermatology. They also have expertise in the management of cosmetic disorders of the skin such as hair loss and scars and the skin changes associated with aging. SODERSTROM DERMATOLOGY CENTER S C NPI is 1710931670. The provider is registered as an organization entity type and is a multi-specialty group.

The provider's business location address is:

4909 N GLEN PARK PLACE RD
PEORIA, IL
ZIP 61614-676
Phone: (309) 674-7546

The provider's authorized official is Christina M Peugh .
The authorized official title is Executive Director and has the following contact phone number (309) 674-7546.

The CLIA number assigned to this NPI record is 14D0648270 - ambulatory surgery center with a certificate type of Certificate of Compliance.

The enumeration date for this NPI number is 5/22/2006 and was last updated on 4/8/2008.


Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No.Taxonomy CodeTaxonomy ClasificationTaxonomy SpecializationLicense NumberLicense StatePrimary
1207ZD0900XPathologyDermatopathologyNo
2208200000XPlastic SurgeryNo
3208600000XSurgeryNo
4207ND0900XDermatologyDermatopathologyNo
5207ND0101XDermatologyMOHS-Micrographic SurgeryNo
6207NS0135XDermatologyProcedural DermatologyNo
7207N00000XDermatologyYes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No.Other Provider IdentifierOther Provider Identifier TypeOther Provider Identifier StateOther Provider Identifier Issuer
1460810MEDICARE PINILLINOIS

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 4/28/2024

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