NPIMap

Organization Active NPI

Integrated Dermatology of Calumet City LLC

  • Dermatology Physician
  • Calumet City, IL
National Provider Identifier
1770966459
Registry record updated Jan 15, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
INTEGRATED DERMATOLOGY OF CALUMET CITY LLC
Practice address
19 River Oaks Dr
Calumet City, IL 60409-5802
Phone
(708) 862-1290
NPI assigned
Jun 30, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 15, 2019

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

Authorized official

Name
Jeffrey Queen
Title
Manager
Phone
(561) 314-2000

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207N00000X Primary

Addresses

Primary practice location

19 River Oaks Dr
Calumet City, IL 60409-5802

Mailing address

4700 Exchange CT Ste 110
Boca Raton, FL 33431-4450
Phone (561) 314-2000

National Provider Directory

National Provider Directory

Locations

275 US Highway 30
Ste 225
Dyer, IN 46311
Phone (219) 865-8800

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1435622400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1547510400000",
    "number": "1770966459",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4700 EXCHANGE CT STE 110",
            "city": "BOCA RATON",
            "state": "FL",
            "postal_code": "334314450",
            "telephone_number": "561-314-2000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "19 RIVER OAKS DR",
            "city": "CALUMET CITY",
            "state": "IL",
            "postal_code": "604095802",
            "telephone_number": "708-862-1290"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INTEGRATED DERMATOLOGY OF CALUMET CITY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-06-30",
        "last_updated": "2019-01-15",
        "status": "A",
        "authorized_official_last_name": "QUEEN",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "561-314-2000"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Calumet City, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 15, 2019; 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.