Provider Demographics
NPI:1669599841
Name:SKIN CARE CENTER OF SOUTHERN IL LLC
Entity type:Organization
Organization Name:SKIN CARE CENTER OF SOUTHERN IL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:NAHASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-244-0031
Mailing Address - Street 1:4107 S WATER TOWER PL
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6293
Mailing Address - Country:US
Mailing Address - Phone:618-244-0031
Mailing Address - Fax:618-244-0056
Practice Address - Street 1:4107 S WATER TOWER PL
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6293
Practice Address - Country:US
Practice Address - Phone:618-244-0031
Practice Address - Fax:618-244-0056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094700207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL152566974412Medicaid
ILCH5023OtherMEDICARE RAILROAD
IL152566974412Medicaid