MEDICARE: MED AESTHETICS, LLC

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	207NS0135X	Procedural Dermatology Physician

General Provider Information

NPI Number	:	1477109270
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MED AESTHETICS, LLC

Provider Business Mailing Address
First Line	:	327 SOUTH BLVD
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60302-2921
Country	:	US
Telephone Number	:	708-676-0288
Fax Number	:

Provider Business Practice Location Address
First Line	:	327 SOUTH BLVD
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60302-2921
Country	:	US
Telephone Number	:	708-676-0288
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. KHAREL BAKER
Credential	:
Telephone Number	:	703-951-3147

Provider Enumeration Date	:	08/16/2019
Last Update Date	:	02/28/2022

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