Healthcare Provider Details

I. General information

NPI: 1003280272
Provider Name (Legal Business Name): JESSIE CHEUNG DERMATOLOGY, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2015
Last Update Date: 11/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 PLAINFIELD RD SUITE B
WILLOWBROOK IL
60527-7600
US

IV. Provider business mailing address

545 PLAINFIELD R. SUITE B
WILLOWBROOK IL
60527
US

V. Phone/Fax

Practice location:
  • Phone: 312-415-8115
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036-112811
License Number StateIL

VIII. Authorized Official

Name: JESSIE CHEUNG
Title or Position: CREDENTIALING
Credential:
Phone: 630-928-5234