Provider Demographics
NPI:1154363844
Name:INNOVATIVE DERMATOLOGY
Entity type:Organization
Organization Name:INNOVATIVE DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DERMATOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:M
Authorized Official - Last Name:THRASH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-907-8454
Mailing Address - Street 1:5140 N CALIFORNIA AVE
Mailing Address - Street 2:SUITE 660
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3645
Mailing Address - Country:US
Mailing Address - Phone:773-907-8454
Mailing Address - Fax:773-907-6336
Practice Address - Street 1:5140 N CALIFORNIA AVE
Practice Address - Street 2:SUITE 660
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3645
Practice Address - Country:US
Practice Address - Phone:773-907-8454
Practice Address - Fax:773-907-6336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty