Provider Demographics
NPI:1235374919
Name:SOUTHWEST DERMATOLOGY, PC
Entity Type:Organization
Organization Name:SOUTHWEST DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-586-4506
Mailing Address - Street 1:7123 W ARCHER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-2203
Mailing Address - Country:US
Mailing Address - Phone:773-586-4506
Mailing Address - Fax:
Practice Address - Street 1:7123 W ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2203
Practice Address - Country:US
Practice Address - Phone:773-586-4506
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207N00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036059742Medicaid
ILD14504OtherUPIN
I22305OtherUPIN
P60539OtherUPIN
H88109OtherUPIN
I60050OtherUPIN
206248Medicare PIN
H88109OtherUPIN
P60539OtherUPIN
K02052Medicare UPIN
R01258Medicare UPIN
K07403Medicare UPIN
IL036059742Medicaid