Healthcare Provider Details

I. General information

NPI: 1821584723
Provider Name (Legal Business Name): DERRICK FARMER, MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2018
Last Update Date: 07/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 W BRADLEY PL STE 100
CHICAGO IL
60618
US

IV. Provider business mailing address

PO BOX 506
NORTHBROOK IL
60065-0506
US

V. Phone/Fax

Practice location:
  • Phone: 224-306-1879
  • Fax: 847-919-6875
Mailing address:
  • Phone: 224-306-1879
  • Fax: 847-919-6875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DERRICK FARMER
Title or Position: MD
Credential: MD
Phone: 224-306-1879