Provider Demographics
NPI:1831125152
Name:AESTHETIC DERMATOLOGY
Entity Type:Organization
Organization Name:AESTHETIC DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONITH
Authorized Official - Middle Name:Y
Authorized Official - Last Name:BREADON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-883-5300
Mailing Address - Street 1:2551 N CLARK ST
Mailing Address - Street 2:SUITE #201
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1798
Mailing Address - Country:US
Mailing Address - Phone:773-883-5300
Mailing Address - Fax:773-883-1807
Practice Address - Street 1:2551 N CLARK ST
Practice Address - Street 2:SUITE #201
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1798
Practice Address - Country:US
Practice Address - Phone:773-883-5300
Practice Address - Fax:773-883-1807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========Medicare UPIN
IL938550Medicare ID - Type Unspecified