Dermassociates LTD

Primary specialty

SpecialistTaxonomy code 174400000X

License

36-49185 Issued in IL

Legal business name

DERMASSOCIATES LTD

Practice address

3608 W Main St
Belleville, IL 62226-6225

Phone

(618) 397-6605

Fax

(618) 277-1251

NPI assigned

Feb 9, 2006

Last updated

Aug 22, 2020By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Dr. Gary John Vicik, M.D.NPI 1295708212

Title

Ceo/Physician

Phone

(618) 397-6605

Specialties & licenses 1

Addresses

Other identifiers 8

Medicare fee-for-service enrollment

Enrolled in IL

Enrollment records 1

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Gary John Vicik, M.D.

  • Specialist
  • Belleville, IL
  • NPI 1295708212
  Medicare reassignment NPD Authorized official
• Jami Lee Mannle, FNP-BC

  • Family Nurse Practitioner
  • O'Fallon, IL
  • NPI 1184857674
  Medicare reassignment NPD

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

{
    "created_epoch": "1139443200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1942273974",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3608 W MAIN ST",
            "city": "BELLEVILLE",
            "state": "IL",
            "postal_code": "622266225",
            "telephone_number": "618-397-6605",
            "fax_number": "618-277-1251"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3608 W MAIN ST",
            "city": "BELLEVILLE",
            "state": "IL",
            "postal_code": "622266225",
            "telephone_number": "618-397-6605",
            "fax_number": "618-277-1251"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DERMASSOCIATES LTD",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-02-09",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "VICIK",
        "authorized_official_first_name": "GARY",
        "authorized_official_middle_name": "JOHN",
        "authorized_official_title_or_position": "CEO/PHYSICIAN",
        "authorized_official_telephone_number": "618-397-6605",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "",
            "desc": "Specialist",
            "state": "IL",
            "license": "36-49185",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GROUP HEALTH PLAN",
            "identifier": "42561V34432",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GREAT WEST",
            "identifier": "202982",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ESSENCE",
            "identifier": "11512",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE SHIELD",
            "identifier": "8215117",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UNITEDHEALTHCARE",
            "identifier": "STL0307017",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AETNA",
            "identifier": "0778106",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HEALTHLINK",
            "identifier": "101263",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ADVANTRA",
            "identifier": "42561V34432",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Mark A Deemer, ATH TR
• Kathleen Denise Defranco, CCC-SLP
• Brandi Delane
• Emilie Diane Delp, LCSW
• Kaselynn Denton, RN, CRNA
• Emily Dermody, FNP
• Vidya Deshpande, M.D.
• Douglas C Despain, MD
• Lexey Deterding
• Radha P Devendrappa, M.D.

• Specialist in Belleville, IL
• Providers in Belleville, IL by specialty
• Specialist in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; 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.