Provider Demographics
NPI:1386180198
Name:DERICK DERMATOLOGY, PLLC
Entity Type:Organization
Organization Name:DERICK DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:DERICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-381-8899
Mailing Address - Street 1:PO BOX 6685
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60197-6685
Mailing Address - Country:US
Mailing Address - Phone:847-381-8899
Mailing Address - Fax:847-381-8999
Practice Address - Street 1:1531 S GROVE AVENUE
Practice Address - Street 2:SUITE 101
Practice Address - City:BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010
Practice Address - Country:US
Practice Address - Phone:847-381-8899
Practice Address - Fax:847-381-8999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-18
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36112935207N00000X
332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213968Medicare PIN