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NPI Code Detail

MEDICARE: AESTHETIC DERMATOLOGY JONITH Y BREADON MD LTD

MEDICARE: AESTHETIC DERMATOLOGY JONITH Y BREADON MD LTD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QM2500XMedical Specialty Clinic/CenterIL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
131602551OTHERILBLUE CROSS BLUE SHIELD

General Provider Information

NPI Number : 1225163967
Entity Type Code : Organization
Provider Name (Legal Business Name) : AESTHETIC DERMATOLOGY JONITH Y BREADON MD LTD
Provider Business Mailing Address
First Line : 1009 W FULTON MARKET
Second Line :
City : CHICAGO
State : IL
Zip : 60607-1222
Country : US
Telephone Number : 312-733-2492
Fax Number : 312-733-2498
Provider Business Practice Location Address
First Line : 1009 W FULTON MARKET
Second Line :
City : CHICAGO
State : IL
Zip : 60607-1222
Country : US
Telephone Number : 312-733-2492
Fax Number : 312-733-2498
Authorized Official
Title or Position : OWNER-PROPRIETOR-HEAD PHYSICIAN
Name : DR. JONITH BREADON
Credential : MD
Telephone Number : 312-733-2498
Provider Enumeration Date : 02/22/2007
Last Update Date : 04/20/2008

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