MEDICARE: DERICK DERMATOLOGY, PLLC

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	332900000X	Non-Pharmacy Dispensing Site
2	207N00000X	Dermatology Physician	36112935	IL

General Provider Information

NPI Number	:	1225526627
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERICK DERMATOLOGY, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 6685
Second Line	:
City	:	CAROL STREAM
State	:	IL
Zip	:	60197-6685
Country	:	US
Telephone Number	:	847-381-8899
Fax Number	:	847-381-8999

Provider Business Practice Location Address
First Line	:	820 W BARTLETT RD
Second Line	:
City	:	BARTLETT
State	:	IL
Zip	:	60103-4402
Country	:	US
Telephone Number	:	847-381-8899
Fax Number	:	847-381-8999

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	AMY DERICK
Credential	:	M.D.
Telephone Number	:	847-381-8899

Provider Enumeration Date	:	05/01/2018
Last Update Date	:	09/09/2022

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