MEDICARE: DEERFIELD DERMATOLOGY ASSOCIATES, LTD.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM2500X	Medical Specialty Clinic/Center
2	207N00000X	Dermatology Physician	042-618435	IL

General Provider Information

NPI Number	:	1225127244
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEERFIELD DERMATOLOGY ASSOCIATES, LTD.

Provider Business Mailing Address
First Line	:	707 LAKE COOK RD
Second Line	:	SUITE #280
City	:	DEERFIELD
State	:	IL
Zip	:	60015-4909
Country	:	US
Telephone Number	:	847-480-0004
Fax Number	:	847-480-8707

Provider Business Practice Location Address
First Line	:	707 LAKE COOK RD
Second Line	:	SUITE #280
City	:	DEERFIELD
State	:	IL
Zip	:	60015-4909
Country	:	US
Telephone Number	:	847-480-0004
Fax Number	:	847-480-8707

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MELISSA GOTTFREDSEN
Credential	:
Telephone Number	:	847-480-0004

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	11/01/2022

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