Provider Demographics
NPI:1063978138
Name:DERMATOLOGY PHYSICIANS SC
Entity type:Organization
Organization Name:DERMATOLOGY PHYSICIANS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOTUNRAYO
Authorized Official - Middle Name:
Authorized Official - Last Name:ADISA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-875-2029
Mailing Address - Street 1:640 N WELLS ST APT 1003
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-3958
Mailing Address - Country:US
Mailing Address - Phone:773-875-2029
Mailing Address - Fax:
Practice Address - Street 1:680 N LAKE SHORE DR STE 1208
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-8701
Practice Address - Country:US
Practice Address - Phone:312-483-4397
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-13
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty