Southwest Dermatology, PC

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

Legal business name

SOUTHWEST DERMATOLOGY, PC

Practice address

7123 W Archer Ave
Chicago, IL 60638-2203

Phone

(773) 586-4506

NPI assigned

Dec 9, 2008

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Julie Moreno

Title

Credentialing Specialist

Phone

(773) 586-4506

Specialties & licenses 2

Addresses

Other identifiers 6

Tax ID family

Southwest Dermatology P2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Southwest Dermatology

  • Dermatology Physician
  • New Lenox, IL
  • NPI 1619260247
  NPD tax ID

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1228780800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1228780800000",
    "number": "1235374919",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7123 W ARCHER AVE",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606382203",
            "telephone_number": "773-586-4506"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7123 W ARCHER AVE",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606382203",
            "telephone_number": "773-586-4506"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHWEST DERMATOLOGY, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-12-09",
        "last_updated": "2008-12-09",
        "status": "A",
        "authorized_official_last_name": "MORENO",
        "authorized_official_first_name": "JULIE",
        "authorized_official_title_or_position": "CREDENTIALING SPECIALIST",
        "authorized_official_telephone_number": "773-586-4506"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dermatology",
            "state": "IL",
            "license": null,
            "primary": true
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": "IL",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036059742",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UPIN",
            "identifier": "D14504",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UPIN",
            "identifier": "I22305",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UPIN",
            "identifier": "P60539",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UPIN",
            "identifier": "H88109",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UPIN",
            "identifier": "I60050",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Southside Primary Care Group SC
• Southtown Medical Center, LLC
• Southview Manor Operator LLC
• Southview Manor,Inc
• T Southward
• Southwest Dermatology, PC
• Southwest Medical Group LTD
• Southwest Optometric Associates P C
• Southwest Senior Center
• Southwest Smiling Dental P.C.

• Dermatology Physician in Chicago, IL
• Providers in Chicago, IL by specialty
• Dermatology Physician in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 9, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.