Organization
SODERSTROM DERMATOLOGY CENTER S C
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. CHRISTINA M PEUGH MBA (EXECUTIVE DIRECTOR)
(309) 674-7546
Entity
Organization
Contact information
Practice address
4909 N GLEN PARK PLACE RD, PEORIA, IL 61614-4676
(309) 674-7546
Mailing address
4909 N GLEN PARK PLACE RD, PEORIA, IL 61614-4676
(309) 674-7546
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
—
—
207ND0101X
MOHS-Micrographic Surgery Physician
—
—
207ND0900X
Dermatopathology Physician
—
—
207NS0135X
Procedural Dermatology Physician
—
—
207ZD0900X
Dermatopathology (Pathology) Physician
—
—
208200000X
Plastic Surgery Physician
—
—
208600000X
Surgery Physician
—
—
Other
Enumeration date
05/22/2006
Last updated
04/08/2008
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