MEDICARE: DERMATOLOGY PHYSICIANS GROUP, LLC

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	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1336507235
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERMATOLOGY PHYSICIANS GROUP, LLC

Provider Business Mailing Address
First Line	:	2156 W SCHOOL ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-6312
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2148 N DAMEN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-4562
Country	:	US
Telephone Number	:	731-698-6756
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	STEPHEN CARTER
Credential	:	MD
Telephone Number	:	731-698-6756

Provider Enumeration Date	:	02/05/2016
Last Update Date	:	02/05/2016

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