=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629164256
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEREK C ARCHER M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2006
-----------------------------------------------------
Last Update Date | 09/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22N285 PEPPER RD SUITE #103
-----------------------------------------------------
City | LAKE BARRINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60010-5982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-732-2739
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 410 ROSEMARY RD
-----------------------------------------------------
City | TORONTO
-----------------------------------------------------
State | ONTARIO
-----------------------------------------------------
Zip | M5P 3E5
-----------------------------------------------------
Country | CA
-----------------------------------------------------
Telephone | 416-617-0102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085B0100X
-----------------------------------------------------
Taxonomy Name | Body Imaging Physician
-----------------------------------------------------
License Number | 36084401
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------