Organization
NAHD SC
Active
Other names
Hartsough Dermatology
Organization subpart
No
Provider details
NPI number
Authorized official
DR. NICOLE ANN HARTSOUGH MD (OWNER)
(815) 226-9642
Entity
Organization
Contact information
Practice address
7402 E RIVERSIDE BLVD, LOVES PARK, IL 61111-5630
(815) 226-9642
(815) 226-9672
Mailing address
7402 E RIVERSIDE BLVD, LOVES PARK, IL 61111-5630
(815) 226-9642
(815) 226-9672
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
K170159
MEMBER #
IL
Enumeration date
08/09/2005
Last updated
11/02/2007
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