Provider Demographics
NPI:1295914174
Name:DERMATOLOGY CONSULTANTS LTD
Entity type:Organization
Organization Name:DERMATOLOGY CONSULTANTS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:IRVING
Authorized Official - Middle Name:H
Authorized Official - Last Name:DISTELITEIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-267-8820
Mailing Address - Street 1:6374 N LINCOLN AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659
Mailing Address - Country:US
Mailing Address - Phone:773-267-8820
Mailing Address - Fax:773-583-2118
Practice Address - Street 1:6374 N LINCOLN AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659
Practice Address - Country:US
Practice Address - Phone:773-267-8820
Practice Address - Fax:773-583-2118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03629454207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1615765OtherBCBS
1615765OtherBCBS
229900Medicare PIN