Provider Demographics
NPI:1023345758
Name:DERMATOLOGY-CHICAGO S C
Entity type:Organization
Organization Name:DERMATOLOGY-CHICAGO S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:SHANKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-372-0150
Mailing Address - Street 1:25 E WASHINGTON ST
Mailing Address - Street 2:SUITE 1131
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-1708
Mailing Address - Country:US
Mailing Address - Phone:312-372-0150
Mailing Address - Fax:312-372-4249
Practice Address - Street 1:25 E WASHINGTON ST
Practice Address - Street 2:SUITE 1131
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-1708
Practice Address - Country:US
Practice Address - Phone:312-372-0150
Practice Address - Fax:312-372-4249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-18
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036064577207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC42738Medicare UPIN