Provider Demographics
NPI:1649587395
Name:MILLENNIUM PARK DERMATOLOGY, S.C.
Entity Type:Organization
Organization Name:MILLENNIUM PARK DERMATOLOGY, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BARBOSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-407-0000
Mailing Address - Street 1:30 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 1429
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3402
Mailing Address - Country:US
Mailing Address - Phone:312-407-0000
Mailing Address - Fax:312-407-0001
Practice Address - Street 1:30 N MICHIGAN AVE
Practice Address - Street 2:SUITE 1429
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3402
Practice Address - Country:US
Practice Address - Phone:312-407-0000
Practice Address - Fax:312-407-0001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106254207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty