Basic Information
| Provider Information | |||||||||
| NPI: | 1386180198 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERICK DERMATOLOGY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6685 | ||||||||
| Address2: | |||||||||
| City: | CAROL STREAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601976685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473818899 | ||||||||
| FaxNumber: | 8473818999 | ||||||||
| Practice Location | |||||||||
| Address1: | 1531 S GROVE AVENUE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BARRINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473818899 | ||||||||
| FaxNumber: | 8473818999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2017 | ||||||||
| LastUpdateDate: | 09/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | DERICK | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8473818899 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
| NPICertificationDate: | 09/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | N | Suppliers | Non-Pharmacy Dispensing Site | 207N00000X | 36112935 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.