Healthcare Provider Details

I. General information

NPI: 1285830166
Provider Name (Legal Business Name): JORDAN CLAIRE CARQUEVILLE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2007
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 Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125053046
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036.130085
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA116000
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number036.130085
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number036.130085
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number036.130085
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: