Organization
DERMASSOCIATES LTD
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. GARY JOHN VICIK M.D. (CEO/PHYSICIAN)
(618) 397-6605
Entity
Organization
Contact information
Practice address
3608 W MAIN ST, BELLEVILLE, IL 62226-6225
(618) 397-6605
(618) 277-1251
Mailing address
3608 W MAIN ST, BELLEVILLE, IL 62226-6225
(618) 397-6605
(618) 277-1251
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
36-49185
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0778106
AETNA
—
01
—
101263
HEALTHLINK
—
01
—
11512
ESSENCE
—
01
—
202982
GREAT WEST
—
01
—
42561V34432
ADVANTRA
—
01
—
8215117
BLUE SHIELD
IL
01
—
STL0307017
UNITEDHEALTHCARE
—
Enumeration date
02/09/2006
Last updated
08/22/2020
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