Provider Demographics
NPI:1366581993
Name:PHYSICIANS LASER AND DERMATOLOGY INSTITUTE OF CHICAGO LLC
Entity type:Organization
Organization Name:PHYSICIANS LASER AND DERMATOLOGY INSTITUTE OF CHICAGO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:M
Authorized Official - Last Name:GARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-280-0890
Mailing Address - Street 1:150 E HURON ST STE 1200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2949
Mailing Address - Country:US
Mailing Address - Phone:312-280-0890
Mailing Address - Fax:312-280-9615
Practice Address - Street 1:150 E HURON ST STE 1200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2949
Practice Address - Country:US
Practice Address - Phone:312-280-0890
Practice Address - Fax:312-280-9615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherTAX ID NO.