MEDICARE: ADVANCED DERMATOLOGY AND AESTHETIC MEDICINE

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	207N00000X	Dermatology Physician	036131459	IL

General Provider Information

NPI Number	:	1275013450
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED DERMATOLOGY AND AESTHETIC MEDICINE

Provider Business Mailing Address
First Line	:	351 W DICKENS AVE APT 4E
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-4615
Country	:	US
Telephone Number	:	402-319-4146
Fax Number	:

Provider Business Practice Location Address
First Line	:	850 S WABASH AVE STE 200
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60605-3642
Country	:	US
Telephone Number	:	847-802-9667
Fax Number	:	408-715-4968

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. MONICA RANI
Credential	:	MD
Telephone Number	:	847-802-9667

Provider Enumeration Date	:	08/17/2018
Last Update Date	:	08/17/2018

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