Healthcare Provider Details

I. General information

NPI: 1710531330
Provider Name (Legal Business Name): JORDAN C. CARQUEVILLE, MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2019
Last Update Date: 01/11/2025
Certification Date: 01/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

737 N MICHIGAN AVE STE 720
CHICAGO IL
60611-6661
US

IV. Provider business mailing address

920 N YORK RD STE 100
HINSDALE IL
60521-3515
US

V. Phone/Fax

Practice location:
  • Phone: 312-319-1978
  • Fax: 312-262-7791
Mailing address:
  • Phone: 312-319-1978
  • Fax: 312-262-7791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARC WEZOWSKI
Title or Position: MANAGING DIRECTOR
Credential: MS, JD
Phone: 312-319-1978