Healthcare Provider Details

I. General information

NPI: 1225526627
Provider Name (Legal Business Name): DERICK DERMATOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2018
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 W BARTLETT RD
BARTLETT IL
60103-4402
US

IV. Provider business mailing address

PO BOX 6685
CAROL STREAM IL
60197-6685
US

V. Phone/Fax

Practice location:
  • Phone: 847-381-8899
  • Fax: 847-381-8999
Mailing address:
  • Phone: 847-381-8899
  • Fax: 847-381-8999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number36112935
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: AMY DERICK
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 847-381-8899