PEORIA AMBULATORY SURGERY CENTER
NPI 1053362343
Clinic/Center - Ambulatory Surgical in Peoria, IL

Q: What is Soderstrom Dermatology Center S C's NPI number?

The NPI number for Soderstrom Dermatology Center S C is 1053362343. It was assigned to this organization in the NPPES registry on May 12, 2006. The provider is doing business as Peoria Ambulatory Surgery Center.

Q: What is Soderstrom Dermatology Center S C's specialty?

The primary specialty registered for this NPI is Clinic/Center, specializing in Ambulatory Surgical, with taxonomy code 261QA1903X.

Active since May 12, 2006CLIA Certified · 3 labs

4909 N GLEN PARK PLACE RD, PEORIA, IL 61614(309) 690-6012 Get Directions Write a Review

NPPES record last updated: June 25, 2008. Verified against the NPPES registry weekly; last sync: August 02, 2026.

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About Peoria Ambulatory Surgery Center NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

PEORIA AMBULATORY SURGERY CENTER (NPI 1053362343) is a healthcare organization registered as an ambulatory surgical in Peoria, Illinois and active in the NPI registry since May 2006. The organization holds 3 active CLIA laboratory certificates and lists Tina M Peugh, Executive Director, Soderstrom Derm, as its authorized official.

NPPES Registry Identity

NPI1053362343

Entity TypeOrganization

Primary Taxonomy261QA1903X

Legal Business NameSODERSTROM DERMATOLOGY CENTER S C

Location Address4909 N GLEN PARK PLACE RDPeoria, IL 61614-4676

Mailing Address4909 N Glen Park Place RdPeoria, IL 61614-4676 · (309) 690-6012

Phone(309) 690-6012

Organization SubpartYes

Authorized OfficialTina M PeughExecutive Director, Soderstrom Derm · (309) 674-7546

Enumeration DateMay 12, 2006

Last NPPES UpdateJune 25, 2008

✔ NPI 1053362343 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyClinic/Center · Ambulatory SurgicalAmbulatory Health Care Facilities

Taxonomy Code261QA1903X

License✔ Licensed in IL · 7001530

4909 N GLEN PARK PLACE RD, Peoria, IL 61614

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Other Names 1

Doing Business AsPeoria Ambulatory Surgery Center

Other Identifiers 2

Medicaid=========001IL

Medicare PIN141058IL

CLIA Laboratory Certificates CMS CLIA 4

Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.

Certificate of Waiver 14D2240670

Soderstrom Dermatology Center, Sc · Peoria, IL

Active · expires Oct 20, 2027

CLIA Number14D2240670

Laboratory TypeAmbulatory Surgery Center

Certificate Effective DateOctober 21, 2025

Certificate Expiration DateOctober 20, 2027

Laboratory DirectorJames M. Jeffries

Laboratory Phone(309) 690-6012

Laboratory LocationSoderstrom Dermatology Center, Sc4909 N Glen Park Place Rd, Peoria, IL 61614

CLIA data matches this NPI record on: Address Phone

This certificate is issued to a laboratory to perform only waived tests.

Certificate of Compliance 14D0648270

Soderstrom Dermatology Center Sc · Peoria, IL

Active · expires Aug 16, 2026

CLIA Number14D0648270

Laboratory TypePhysician Office

Certificate Effective DateAugust 17, 2024

Certificate Expiration DateAugust 16, 2026

Laboratory DirectorJoshua Kentosh

Laboratory Phone(309) 674-7546

Laboratory LocationSoderstrom Dermatology Center Sc4909 N Glen Park Place, Peoria, IL 61614

CLIA data matches this NPI record on: Address Phone

This certificate is issued to a laboratory after an inspection that finds the laboratory to be in compliance with all applicable CLIA requirements.

Certificate for Provider-Performed Microscopy Procedures (PPMP) 16D2228982

Soderstrom Dermatology Center Sc - Muscatine · Muscatine, IA

Active · expires Jul 5, 2027

CLIA Number16D2228982

Laboratory TypePhysician Office

Certificate Effective DateJuly 6, 2025

Certificate Expiration DateJuly 5, 2027

Laboratory DirectorMartin M. Pereira

Laboratory Phone(309) 674-7546

Laboratory LocationSoderstrom Dermatology Center Sc - Muscatine2300 A Park Avenue, Muscatine, IA 52761

CLIA data matches this NPI record on: Phone

This certificate is issued to a laboratory in which a physician, midlevel practitioner or dentist performs no tests other than the microscopy procedures. This certificate permits the laboratory to also perform waived tests.

Certificate of Compliance 14D2196441

Soderstrom Dermatology Center S C · Peoria, IL

Expired · Jul 31, 2026

CLIA Number14D2196441

Laboratory TypeAncillary Testing Site In Health Care Center

Certificate Effective DateMarch 29, 2024

Certificate Expiration DateJuly 31, 2026

Laboratory DirectorTesfu L. Hailu

Laboratory Phone(309) 691-7479

Laboratory LocationSoderstrom Dermatology Center S C5010 North Glen Park Place, Peoria, IL 61614

CLIA data matches this NPI record on: Name

This certificate is issued to a laboratory after an inspection that finds the laboratory to be in compliance with all applicable CLIA requirements.

Areas of Expertise CMS Part B claims 27

Services this provider delivered to Medicare fee-for-service patients, from the CMS Medicare utilization data. Higher counts generally reflect more experience with a service; care delivered outside Medicare is not included.

Removal and microscopic exam of growth of head, neck, hands, feet, or genitals, 1-5 tissue blocks 17311

This procedure involves the careful removal of a growth from the head, neck, hands, or feet. The removed tissue, divided into 1-5 blocks, is then examined under a microscope to study its characteristics and determine the nature of the growth.

698 services604 patients

Complicated repair of wound of scalp, arms, or legs, 2.6-7.5 cm 13121

This is a procedure to repair a complex wound on your scalp, arm, or leg that is 2.6-7.5 cm long. It involves cleaning, removing damaged tissue, and stitching the wound to promote healing. It's performed under local or general anesthesia.

274 services250 patients

Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 2.6-7.5 cm 13132

This procedure involves the complex repair of a wound in areas like the forehead, cheeks, chin, mouth, neck, underarms, hands, or feet. The wound size ranges from 2.6-7.5 cm. The process includes cleaning, removing damaged tissue, and stitching the wound for proper healing.

254 services235 patients

Complicated repair of wound of trunk, 2.6-7.5 cm 13101

This service involves the intricate repair of a wound on your body's main structure, between your neck and limbs. The wound measures 2.6-7.5 cm. The procedure includes deep-layer stitching and may involve repairing damaged tissue.

128 services123 patients

Repair of wound of eyelids, nose, ears, or lips by transferring skin, 10.0 sq cm or less 14060

This procedure involves repairing a wound on the eyelids, nose, ears, or lips by moving a small piece of skin (10.0 sq cm or less) from one area to another. The goal is to heal the wound and restore the function and appearance of the affected area.

119 services117 patients

Removal of cancer skin growth of body, arms, or legs, 1.1-2.0 cm 11602

This procedure involves the surgical removal of a cancerous skin growth on the body, arms, or legs. The growth is between 1.1 and 2.0 cm in size. The goal is to eliminate cancer cells and prevent them from spreading to other parts of the body.

90 services84 patients

Complicated repair of wound of eyelids, nose, ears, or lip, 2.6-7.5 cm 13152

This procedure involves repairing a wound on your eyelids, nose, ears, or lip that is between 2.6 and 7.5 cm long. It's considered complicated due to the location and size. The doctor will clean, treat, and stitch the wound to promote healing.

87 services82 patients

Removal of cancer skin growth of body, arms, or legs, 2.1-3.0 cm 11603

This procedure involves the removal of a cancerous skin growth, between 2.1 and 3.0 cm, from the body, arms, or legs. The area is numbed, then the growth is carefully cut out. The goal is to eliminate all cancer cells while minimizing scarring.

80 services78 patients

Removal of cancer skin growth of body, arms, or legs, more than 4.0 cm 11606

This procedure involves surgically removing a cancerous skin growth larger than 4.0 cm on your body, arms, or legs. It's a crucial step in preventing the spread of cancer. Local anesthesia is typically used, and recovery time varies. It's a common and safe procedure.

68 services63 patients

Removal of noncancer skin growth of body, arms, or legs, 1.1-2.0 cm 11402

This procedure involves the removal of a noncancerous skin growth on the body, arms, or legs that is between 1.1 and 2.0 cm in size. It's a safe and routine procedure performed by a medical professional to improve your skin health and appearance.

34 services34 patients

Removal of cancer skin growth of body, arms, or legs, 3.1-4.0 cm 11604

This procedure involves removing a cancerous skin growth measuring 3.1-4.0 cm on the body, arms, or legs. The area is numbed, then the growth is carefully cut out. The wound is stitched for healing. Regular follow-ups ensure complete removal and recovery.

34 services34 patients

Removal and microscopic exam of growth of trunk, arms, or legs, 1-5 tissue blocks 17313

This procedure involves the removal of a growth from your trunk, arms, or legs. The removed tissue, divided into 1-5 blocks, is then examined under a microscope to identify any abnormalities. This helps in diagnosing and planning further treatment.

34 services33 patients

Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm 12042

This is a procedure to mend a moderate wound between 2.6-7.5 cm on your neck, hands, or feet. It involves cleaning the wound, removing any damaged tissue, and stitching it back together to promote healing and minimize scarring.

29 services29 patients

Repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet by transferring skin, 10.1-30.0 sq cm 14041

This procedure involves repairing a wound on specified body areas by transferring skin from another part of the body. The transferred skin, measuring between 10.1 to 30.0 square cm, aids in healing the wound and restoring the skin's normal function.

25 services25 patients

Full thickness skin graft to nose, ears, eyelids, or lips, 20.0 sq cm or less 15260

A full thickness skin graft is a procedure where a layer of skin is taken from one area of the body and transplanted to another. If it's done on the nose, ears, eyelids, or lips, it helps restore these areas when damaged. The size of the graft is 20.0 sq cm or less.

24 services23 patients

Removal of noncancer skin growth of body, arms, or legs, 2.1-3.0 cm 11403

This is a procedure where a noncancerous skin growth, sized 2.1-3.0 cm, on the body, arms, or legs is removed. It's typically done under local anesthesia. The process involves cutting out the growth and stitching the skin back together. The aim is to eliminate discomfort and prevent potential health issues.

23 services23 patients

Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm 12053

This procedure involves the repair of a medium-sized wound (5.1-7.5 cm) on the face, ears, eyelids, nose, lips, or mouth. It's more complex than a simple stitch-up, often requiring layered stitches to ensure proper healing and minimize scarring.

22 services22 patients

Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm 12052

This procedure involves repairing a wound on the face, ears, eyelids, nose, lips, or mouth that measures between 2.6-5.0 cm. The process includes cleaning, suturing if necessary, and dressing the wound to promote healing and prevent infection.

20 services20 patients

Repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet by transferring skin, 10.0 sq cm or less 14040

This procedure involves repairing a wound on various body parts by transferring skin from another area. The transferred skin, up to 10.0 sq cm, helps to cover the wound, promoting healing and reducing scarring. It's a common method for treating larger or deeper wounds.

19 services19 patients

Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm 12032

This procedure involves the repair of a wound between 2.6-7.5 cm located on the scalp, underarms, trunk, arms, or legs. The process includes cleaning, debridement (removal of damaged tissue), and suturing (stitching) of the wound to promote healing.

18 services17 patients

Repair of wound of eyelids, nose, ears, or lips by transferring skin, 10.1-30.0 sq cm 14061

This procedure involves repairing a wound on the eyelids, nose, ears, or lips by transferring skin from another part of the body. The size of the skin transferred will be between 10.1 to 30.0 square centimeters. It is performed to restore function and appearance.

17 services17 patients

Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm 11422

This procedure involves the removal of a noncancerous skin growth in areas such as the scalp, neck, hands, or feet. The growth being removed is between 1.1 to 2.0 cm in size. The process is safe, typically involves local anesthesia, and is performed by a healthcare professional.

16 services15 patients

Complicated repair of wound of eyelids, nose, ears, or lip, 1.1-2.5 cm 13151

This procedure involves the intricate repair of a wound that is 1.1 to 2.5 cm long on your eyelids, nose, ears, or lip. The goal is to mend the wound carefully to preserve function and minimize scarring. The process may involve stitching and other techniques.

14 services14 patients

Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 1.1-2.5 cm 13131

This procedure involves the complex repair of a wound in areas like the forehead, cheeks, chin, mouth, neck, underarms, hands, or feet. The wound size is between 1.1-2.5 cm. This repair may involve multiple layers of sutures and could require reconstruction of the skin.

13 services13 patients

Biopsy of related skin growth, first growth 11102

A biopsy of a skin growth involves taking a small sample of the growth to examine it under a microscope. This helps determine if the growth is harmful. The procedure is typically quick, with minimal discomfort. It's a crucial step in ensuring your skin's health.

12 services12 patients

Removal of cancer skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm 11622

This procedure involves the careful removal of a cancerous skin growth measuring between 1.1 to 2.0 cm, located on the scalp, neck, hands, or feet. The goal is to eliminate the cancer and prevent its spread. This is done under local anesthesia to minimize discomfort.

11 services11 patients

Removal of growth of tendon finger or hand 26160

This procedure involves the surgical removal of abnormal growths on tendons in the finger or hand. These growths can cause discomfort or restrict movement. The process aims to alleviate pain and restore function to the affected area. It's done under anesthesia.

11 services11 patients

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Other Providers at the Same Location NPPES 16

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

TAYLOR MARIE WELLS MD

Dermatology