Basic Information
| Provider Information | |||||||||
| NPI: | 1770966459 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED DERMATOLOGY OF CALUMET CITY LLC | ||||||||
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| Address1: | 4700 EXCHANGE CT STE 110 | ||||||||
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| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334314450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613142000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 19 RIVER OAKS DR | ||||||||
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| City: | CALUMET CITY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604095802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7088621290 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2015 | ||||||||
| LastUpdateDate: | 01/15/2019 | ||||||||
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| AuthorizedOfficialLastName: | QUEEN | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5613142000 | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.