Basic Information
| Provider Information | |||||||||
| NPI: | 1366009664 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERICK DERMATOLOGY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 SPRING RD STE 210 | ||||||||
| Address2: | |||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605239063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473818899 | ||||||||
| FaxNumber: | 8473818999 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 SPRING RD STE 210 | ||||||||
| Address2: | |||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605239063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473818899 | ||||||||
| FaxNumber: | 8473818999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2019 | ||||||||
| LastUpdateDate: | 09/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | DERICK | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | JANE | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8473818899 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DERICK DERMATOLOGY | ||||||||
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| NPICertificationDate: | 09/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | N | Suppliers | Non-Pharmacy Dispensing Site | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.