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General NPI Number Information
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NPI Number | 1295914174
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Entity Type | Organization
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Legal Business Name | DERMATOLOGY CONSULTANTS LTD
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Dates
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Enumeration Date | 10/29/2007
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Last Update Date | 10/29/2007
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Provider Practice Location Address
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Address Line | 6374 N LINCOLN AVE SUITE 202
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City | CHICAGO
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State | IL
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Zip | 60659
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Country | US
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Telephone | 773-267-8820
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Fax | 773-583-2118
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Provider Business Mailing Address
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Address Line | 6374 N LINCOLN AVE SUITE 202
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City | CHICAGO
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State | IL
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Zip | 60659
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Country | US
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Telephone | 773-267-8820
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Fax | 773-583-2118
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. IRVING H DISTELITEIM
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Credential | MD
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Telephone | 773-267-8820
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 03629454
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License Number State | IL
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