NPIMap

Organization Active NPI

St Joseph Dermatology and Vein Clinic PLLC

  • Dermatology Physician
  • Saint Joseph, MI
National Provider Identifier
1407309560
Registry record updated Jan 26, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
License
4301079801 Issued in MI
Legal business name
ST JOSEPH DERMATOLOGY AND VEIN CLINIC PLLC
Practice address
2500 Niles Rd Ste 10a
Saint Joseph, MI 49085-3272
Phone
(773) 351-2862
Fax
(773) 358-2767
NPI assigned
Jul 25, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 26, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Vassilios Athanasios Dimitropoulos, M.D.NPI 1194838045
Title
Physician/ Owner/ President
Phone
(773) 351-2862

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207N00000X 4301079801 MI Primary
MOHS-Micrographic Surgery PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207ND0101X 4301079801 MI
Procedural Dermatology PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207NS0135X 4301079801 MI

Addresses

Primary practice location

2500 Niles Rd Ste 10a
Saint Joseph, MI 49085-3272

Mailing address

745 S Park Ave
Hinsdale, IL 60521-4645
Phone (773) 351-2862

Other identifiers 1

IdentifierTypeStateIssuer
1194838045MedicaidMI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20160831000391 MI Part B Supplier - Clinic/Group Practice 3476849407 Receives reassigned benefits from 7 practitioners
Practice locations: Saint Joseph, MI

National Provider Directory

National Provider Directory

Locations

2500 Niles Rd
Ste 10A
Saint Joseph, MI 49085
Phone (269) 428-5199

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1469404800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1485388800000",
    "number": "1407309560",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "745 S PARK AVE",
            "city": "HINSDALE",
            "state": "IL",
            "postal_code": "605214645",
            "telephone_number": "773-351-2862",
            "fax_number": "773-358-2767"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2500 NILES RD STE 10A",
            "city": "SAINT JOSEPH",
            "state": "MI",
            "postal_code": "490853272",
            "telephone_number": "773-351-2862",
            "fax_number": "773-358-2767"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST JOSEPH DERMATOLOGY AND VEIN CLINIC PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-07-25",
        "last_updated": "2017-01-26",
        "status": "A",
        "authorized_official_last_name": "DIMITROPOULOS",
        "authorized_official_first_name": "VASSILIOS",
        "authorized_official_middle_name": "ATHANASIOS",
        "authorized_official_title_or_position": "PHYSICIAN/ OWNER/ PRESIDENT",
        "authorized_official_telephone_number": "773-351-2862",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dermatology",
            "state": "MI",
            "license": "4301079801",
            "primary": true
        },
        {
            "code": "207ND0101X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dermatology, MOHS-Micrographic Surgery",
            "state": "MI",
            "license": "4301079801",
            "primary": false
        },
        {
            "code": "207NS0135X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dermatology, Procedural Dermatology",
            "state": "MI",
            "license": "4301079801",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1194838045",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Saint Joseph, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 26, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.