Healthcare Provider Details

I. General information

NPI: 1366927493
Provider Name (Legal Business Name): REDDY DERMATOLOGY, S CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2018
Last Update Date: 08/31/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 63RD ST STE 101
DOWNERS GROVE IL
60516-2000
US

IV. Provider business mailing address

412 63RD ST STE 101
DOWNERS GROVE IL
60516-2000
US

V. Phone/Fax

Practice location:
  • Phone: 630-855-8355
  • Fax:
Mailing address:
  • Phone: 815-210-1885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: TERENCE CHIRAMEL
Title or Position: ADMINISTRATOR
Credential: MBBS, MBA
Phone: 630-855-8355