Healthcare Provider Details

I. General information

NPI: 1053024554
Provider Name (Legal Business Name): LEGACY DERMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2022
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 HUNTINGTON DR N
ALGONQUIN IL
60102-4419
US

IV. Provider business mailing address

2230 HUNTINGTON DR N
ALGONQUIN IL
60102-4419
US

V. Phone/Fax

Practice location:
  • Phone: 415-802-1310
  • Fax: 847-960-3675
Mailing address:
  • Phone: 847-603-4146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: LAURENCE BRADLEY
Title or Position: MD/OWNER
Credential: MD
Phone: 415-802-1310