Organization
SOUTHWEST DERMATOLOGY, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JULIE MORENO (CREDENTIALING SPECIALIST)
(773) 586-4506
Entity
Organization
Contact information
Practice address
7123 W ARCHER AVE, CHICAGO, IL 60638-2203
(773) 586-4506
Mailing address
7123 W ARCHER AVE, CHICAGO, IL 60638-2203
(773) 586-4506
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
—
IL
363L00000X
Nurse Practitioner
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036059742
—
IL
01
—
D14504
UPIN
IL
01
—
H88109
UPIN
—
01
—
I22305
UPIN
—
01
—
I60050
UPIN
—
01
—
P60539
UPIN
—
Enumeration date
12/09/2008
Last updated
12/09/2008
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