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General NPI Number Information
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NPI Number | 1861943888
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Entity Type | Organization
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Legal Business Name | NORTHSIDE DERMATOLOGY, S.C.
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Dates
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Enumeration Date | 10/14/2016
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Last Update Date | 04/20/2020
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Provider Practice Location Address
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Address Line | 1663 W CARMEN AVE
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City | CHICAGO
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State | IL
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Zip | 60640-2701
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Country | US
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Telephone | 312-420-7409
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Fax |
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Provider Business Mailing Address
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Address Line | 1663 W CARMEN AVE
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City | CHICAGO
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State | IL
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Zip | 60640-2701
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRACTICE OWNER
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Name | DR. JAMES A IDA
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Credential |
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Telephone | 773-293-7500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 036.132972
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License Number State | IL
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