Healthcare Provider Details

I. General information

NPI: 1083023295
Provider Name (Legal Business Name): MEL A DERMODY H.I.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2014
Last Update Date: 08/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2844 N.SHERIDAN ROAD
CHICAGO IL
60657
US

IV. Provider business mailing address

11457 OLDE CABIN RD SUITE 337
CREVE COEUR MO
63141-7139
US

V. Phone/Fax

Practice location:
  • Phone: 773-697-3983
  • Fax: 773-697-7839
Mailing address:
  • Phone: 314-888-6653
  • Fax: 314-888-6662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number3189
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: