MEDICARE: CHICAGO COSMETIC SURGERY AND DERMATOLOGY SC

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	036-102098	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1634805	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1407068000
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICAGO COSMETIC SURGERY AND DERMATOLOGY SC

Provider Business Mailing Address
First Line	:	515 N STATE ST STE 900
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60654-9104
Country	:	US
Telephone Number	:	312-245-9965
Fax Number	:	312-245-9964

Provider Business Practice Location Address
First Line	:	515 N STATE ST STE 900
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60654-9104
Country	:	US
Telephone Number	:	312-245-9965
Fax Number	:	312-245-9964

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	CAROLYN JACOB
Credential	:
Telephone Number	:	312-245-9965

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	04/14/2026

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Directions to “CHICAGO COSMETIC SURGERY AND DERMATOLOGY SC ” Practice Location

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