Healthcare Provider Details

I. General information

NPI: 1619890571
Provider Name (Legal Business Name): ELITE DERMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 N HALSTED ST STE 500
CHICAGO IL
60657-5194
US

IV. Provider business mailing address

3000 N HALSTED ST STE 500
CHICAGO IL
60657-5194
US

V. Phone/Fax

Practice location:
  • Phone: 773-871-7000
  • Fax:
Mailing address:
  • Phone:
  • 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

VIII. Authorized Official

Name: EDWARD PRODANOVIC
Title or Position: OWNER
Credential: MD
Phone: 415-802-1310