Provider Demographics
NPI:1619260247
Name:SOUTHWEST DERMATOLOGY
Entity Type:Organization
Organization Name:SOUTHWEST DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D./
Authorized Official - Prefix:
Authorized Official - First Name:CHEUK
Authorized Official - Middle Name:W
Authorized Official - Last Name:YUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-463-8989
Mailing Address - Street 1:1870 SILVER CROSS BOULEVARD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451
Mailing Address - Country:US
Mailing Address - Phone:815-463-8989
Mailing Address - Fax:815-463-8948
Practice Address - Street 1:1870 SILVER CROSS BOULEVARD
Practice Address - Street 2:SUITE 250
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451
Practice Address - Country:US
Practice Address - Phone:815-463-8989
Practice Address - Fax:815-463-8948
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHWEST DERMATOLOGY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-16
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36059742207N00000X
IL36111373207N00000X
IL36116569207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty