Healthcare Provider Details

I. General information

NPI: 1467074617
Provider Name (Legal Business Name): DEWOLFE AESTHETIC SERVICES SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2020
Last Update Date: 05/11/2020
Certification Date: 05/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3357 N. SOUTHPORT AVEUNE
CHICAGO IL
60657
US

IV. Provider business mailing address

3357 N. SOUTHPORT AVEUNE
CHICAGO IL
60657
US

V. Phone/Fax

Practice location:
  • Phone: 434-284-8770
  • Fax: 914-206-4144
Mailing address:
  • Phone: 434-284-8770
  • Fax: 914-206-4144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JUDITH POLHEMUS
Title or Position: BILLING MANAGER
Credential:
Phone: 434-284-8770