Organization
DISTINCTIVE DERMATOLOGYLTD
Active
Other names
Gregory & Associates Dermatology, LTD
Organization subpart
No
Provider details
NPI number
Authorized official
MS. SUSAN L. JOURNAGAN M.D. (PRESIDENT)
(618) 233-7666
Entity
Organization
Contact information
Practice address
510 FULLERTON RD, SWANSEA, IL 62226-2970
(618) 233-7666
(618) 233-7461
Mailing address
510 FULLERTON ROAD, SWANSEA, IL 62226-2970
(618) 233-7666
(618) 233-7461
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
—
—
363L00000X
Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
8200530
BCBS GROUP LEGACY #
IL
01
—
CA2289
MEDICARE RR GROUP PTAN
IL
Enumeration date
12/13/2006
Last updated
12/26/2014
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