Provider Demographics
NPI:1710531330
Name:JORDAN C. CARQUEVILLE, MD LLC
Entity Type:Organization
Organization Name:JORDAN C. CARQUEVILLE, MD LLC
Other - Org Name:DERM INSTITUTE OF CHICAGO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:WEZOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MS, JD
Authorized Official - Phone:312-319-1978
Mailing Address - Street 1:920 N YORK RD STE 100
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3515
Mailing Address - Country:US
Mailing Address - Phone:312-319-1978
Mailing Address - Fax:312-262-7791
Practice Address - Street 1:737 N MICHIGAN AVE STE 720
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-6661
Practice Address - Country:US
Practice Address - Phone:312-319-1978
Practice Address - Fax:312-262-7791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-31
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty