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General NPI Number Information
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NPI Number | 1487116240
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Entity Type | Organization
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Legal Business Name | CONRAD PETERSEN DERMATOLOGY SC
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Dates
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Enumeration Date | 04/02/2019
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Last Update Date | 03/19/2020
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Provider Practice Location Address
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Address Line | 2845 N SHERIDAN
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City | CHICAGO
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State | IL
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Zip | 60657
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Country | US
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Telephone | 773-832-7443
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Fax | 773-295-4126
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Provider Business Mailing Address
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Address Line | 2845 N SHERIDAN
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City | CHICAGO
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State | IL
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Zip | 60657
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Country | US
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Telephone | 773-832-7443
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Fax | 773-295-4126
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Authorized Official
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Title or Position | OWNER
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Name | ERIN PETERSEN
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Credential | MD
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Telephone | 314-518-0403
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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 |
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License Number State |
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