Provider Demographics
NPI:1225163967
Name:AESTHETIC DERMATOLOGY JONITH Y BREADON MD LTD
Entity Type:Organization
Organization Name:AESTHETIC DERMATOLOGY JONITH Y BREADON MD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-PROPRIETOR-HEAD PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JONITH
Authorized Official - Middle Name:
Authorized Official - Last Name:BREADON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-733-2498
Mailing Address - Street 1:1009 W FULTON MARKET
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-1222
Mailing Address - Country:US
Mailing Address - Phone:312-733-2492
Mailing Address - Fax:312-733-2498
Practice Address - Street 1:1009 W FULTON MARKET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-1222
Practice Address - Country:US
Practice Address - Phone:312-733-2492
Practice Address - Fax:312-733-2498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31602551OtherBLUE CROSS BLUE SHIELD
IL=========OtherFIRST HEALTH
IL=========OtherONE HEALTH/GREAT WEST
IL=========OtherHFN
IL=========OtherONE HEALTH/GREAT WEST