Provider Demographics
NPI:1790706547
Name:NORTHWEST DERMATOLOGY, S.C.
Entity Type:Organization
Organization Name:NORTHWEST DERMATOLOGY, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BACARELLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-884-8096
Mailing Address - Street 1:2500 W. HIGGINS ROAD
Mailing Address - Street 2:SUITE 1040
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60169
Mailing Address - Country:US
Mailing Address - Phone:847-884-8096
Mailing Address - Fax:847-884-8125
Practice Address - Street 1:2500 W. HIGGINS ROAD
Practice Address - Street 2:SUITE 1040
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169
Practice Address - Country:US
Practice Address - Phone:847-884-8096
Practice Address - Fax:847-884-8125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001617988OtherBC/BS
IL677490Medicare ID - Type Unspecified