Provider Demographics
NPI:1255424552
Name:DERMATOLOGY SPECIALIST, LTD
Entity type:Organization
Organization Name:DERMATOLOGY SPECIALIST, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRSCHENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:7733-271-4442
Mailing Address - Street 1:2740 W FOSTER AVE SUITE 305
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625
Mailing Address - Country:US
Mailing Address - Phone:773-271-4442
Mailing Address - Fax:773-271-4474
Practice Address - Street 1:2740 W FOSTER AVE SUITE 305
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625
Practice Address - Country:US
Practice Address - Phone:773-271-4442
Practice Address - Fax:773-271-4474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036035278174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036035278Medicaid
ILDG9713OtherRAIL ROAD MEDICARE
C41400Medicare UPIN
IL036035278Medicaid