MEDICARE: SOUTHWEST DERMATOLOGY, PC

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
1	363L00000X	Nurse Practitioner		IL
2	207N00000X	Dermatology Physician		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	D14504	OTHER	IL	UPIN
3	I22305	OTHER		UPIN
4	P60539	OTHER		UPIN
5	H88109	OTHER		UPIN
6	I60050	OTHER		UPIN

General Provider Information

NPI Number	:	1235374919
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWEST DERMATOLOGY, PC

Provider Business Mailing Address
First Line	:	7123 W ARCHER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60638-2203
Country	:	US
Telephone Number	:	773-586-4506
Fax Number	:

Provider Business Practice Location Address
First Line	:	7123 W ARCHER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60638-2203
Country	:	US
Telephone Number	:	773-586-4506
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	JULIE MORENO
Credential	:
Telephone Number	:	773-586-4506

Provider Enumeration Date	:	12/09/2008
Last Update Date	:	12/09/2008

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Directions to “SOUTHWEST DERMATOLOGY, PC ” Practice Location

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