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General NPI Number Information
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NPI Number | 1447601414
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Entity Type | Organization
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Legal Business Name | CENTER FOR DERMATOLOGY AND AESTHETIC MEDICINE, LLC
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Dates
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Enumeration Date | 06/30/2016
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Last Update Date | 06/30/2016
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Provider Practice Location Address
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Address Line | 755 N WELLS ST SUITE 201
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City | CHICAGO
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State | IL
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Zip | 60654-3520
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Country | US
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Telephone | 312-380-6747
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Fax | 312-348-7229
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Provider Business Mailing Address
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Address Line | 755 N WELLS ST SUITE 201
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City | CHICAGO
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State | IL
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Zip | 60654-3520
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Country | US
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Telephone | 312-380-6747
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Fax | 312-348-7229
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. FAIYAAZ AHMAD KALIMULLAH
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Credential | M.D.
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Telephone | 312-380-6747
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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 | 036139965
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License Number State | IL
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