Provider Demographics
NPI:1497972418
Name:ACADEMIC & CLINICAL ASSOCIATES IN DERMATOLOGY LTD
Entity Type:Organization
Organization Name:ACADEMIC & CLINICAL ASSOCIATES IN DERMATOLOGY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATTORNEY
Authorized Official - Prefix:
Authorized Official - First Name:MORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-715-6848
Mailing Address - Street 1:7047 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1015
Mailing Address - Country:US
Mailing Address - Phone:708-383-0300
Mailing Address - Fax:
Practice Address - Street 1:7047 NORTH AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1015
Practice Address - Country:US
Practice Address - Phone:708-383-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036035438207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01615155OtherBLUE CROSS BLUE SHIELD
IL765760Medicare ID - Type Unspecified
IL419320Medicare ID - Type Unspecified
IL966650Medicare PIN