Organization
CHICAGO COSMETIC SURGERY AND DERMATOLOGY SC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CAROLYN JACOB (MEDICAL DIRECTOR)
(312) 245-9965
Entity
Organization
Contact information
Practice address
515 N STATE ST STE 900, CHICAGO, IL 60654-9104
(312) 245-9965
(312) 245-9964
Mailing address
515 N STATE ST STE 900, CHICAGO, IL 60654-9104
(312) 245-9965
(312) 245-9964
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
036-102098
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1634805
BLUE CROSS BLUE SHIELD
IL
Enumeration date
05/04/2007
Last updated
04/14/2026
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