Healthcare Provider Details

I. General information

NPI: 1801285929
Provider Name (Legal Business Name): MEDICAL DERMATOLOGY ASSOCIATES OF CHICAGO, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2015
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 W ERIE ST SUITE 350
CHICAGO IL
60654-6903
US

IV. Provider business mailing address

363 W ERIE ST SUITE 350
CHICAGO IL
60654-6903
US

V. Phone/Fax

Practice location:
  • Phone: 312-995-1955
  • Fax: 312-995-1956
Mailing address:
  • Phone: 312-995-1955
  • Fax: 312-995-1956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PETER LIO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 312-995-1955