Healthcare Provider Details

I. General information

NPI: 1366009664
Provider Name (Legal Business Name): DERICK DERMATOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2019
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 SPRING RD STE 210
OAK BROOK IL
60523-9063
US

IV. Provider business mailing address

1900 SPRING RD STE 210
OAK BROOK IL
60523-9063
US

V. Phone/Fax

Practice location:
  • Phone: 847-381-8899
  • Fax: 847-381-8999
Mailing address:
  • Phone: 847-381-8899
  • Fax: 847-381-8999

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: AMY JANE DERICK
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 847-381-8899