Provider Demographics
NPI:1467074617
Name:DEWOLFE AESTHETIC SERVICES SC
Entity Type:Organization
Organization Name:DEWOLFE AESTHETIC SERVICES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:POLHEMUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-284-8770
Mailing Address - Street 1:3357 N. SOUTHPORT AVEUNE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657
Mailing Address - Country:US
Mailing Address - Phone:434-284-8770
Mailing Address - Fax:914-206-4144
Practice Address - Street 1:3357 N. SOUTHPORT AVEUNE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657
Practice Address - Country:US
Practice Address - Phone:434-284-8770
Practice Address - Fax:914-206-4144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty