=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649587395
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MILLENNIUM PARK DERMATOLOGY, S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2010
-----------------------------------------------------
Last Update Date | 09/01/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 N MICHIGAN AVE SUITE 1429
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60602-3402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-407-0000
-----------------------------------------------------
Fax | 312-407-0001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 N MICHIGAN AVE SUITE 1429
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60602-3402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-407-0000
-----------------------------------------------------
Fax | 312-407-0001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN OWNER
-----------------------------------------------------
Name | DR. VICTORIA BARBOSA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 312-407-0000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 036106254
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------