Provider Demographics
NPI:1528273505
Name:ADVANCED DERMATOLOGY,LLC
Entity type:Organization
Organization Name:ADVANCED DERMATOLOGY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:FORMAN
Authorized Official - Last Name:TAUB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-459-6400
Mailing Address - Street 1:275 PARKWAY DR
Mailing Address - Street 2:SUITE 521
Mailing Address - City:LINCOLNSHIRE
Mailing Address - State:IL
Mailing Address - Zip Code:60069-4341
Mailing Address - Country:US
Mailing Address - Phone:847-459-6400
Mailing Address - Fax:847-459-4610
Practice Address - Street 1:275 PARKWAY DR
Practice Address - Street 2:SUITE 521
Practice Address - City:LINCOLNSHIRE
Practice Address - State:IL
Practice Address - Zip Code:60069-4341
Practice Address - Country:US
Practice Address - Phone:847-459-6400
Practice Address - Fax:847-459-4610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL204639Medicare ID - Type Unspecified
ILC40069Medicare UPIN