Provider Demographics
NPI:1316014723
Name:MEDICAL SURGICAL DERMATOLOGY, SC
Entity Type:Organization
Organization Name:MEDICAL SURGICAL DERMATOLOGY, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:WHITNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-788-3885
Mailing Address - Street 1:3253 HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-2996
Mailing Address - Country:US
Mailing Address - Phone:708-788-3885
Mailing Address - Fax:708-788-6885
Practice Address - Street 1:3253 HARLEM AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2996
Practice Address - Country:US
Practice Address - Phone:708-788-3885
Practice Address - Fax:708-788-6885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD13409Medicare UPIN