MEDICARE: SOUTHWEST DERMATOLOGY, PC

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	060008763	IL
2	207ND0101X	MOHS-Micrographic Surgery Physician	060008763	IL
3	207NI0002X	Clinical & Laboratory Dermatological Immunology Physician	060008763	IL
4	207NS0135X	Procedural Dermatology Physician	060008763	IL
5	207ND0900X	Dermatopathology Physician	060008763	IL

General Provider Information

NPI Number	:	1528491321
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWEST DERMATOLOGY, PC

Provider Business Mailing Address
First Line	:	7123 W ARCHER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60638-2203
Country	:	US
Telephone Number	:	773-586-4506
Fax Number	:

Provider Business Practice Location Address
First Line	:	7123 W ARCHER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60638-2203
Country	:	US
Telephone Number	:	773-586-4506
Fax Number	:	773-586-5044

Authorized Official
Title or Position	:	CEO/OWNER
Name	:	DR. CHEUK W YUNG
Credential	:	M.D.
Telephone Number	:	773-586-4506

Provider Enumeration Date	:	08/15/2013
Last Update Date	:	12/12/2013

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