1225163967 NPI number — AESTHETIC DERMATOLOGY JONITH Y BREADON MD LTD

Table of content: (NPI 1225163967)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225163967 NPI number — AESTHETIC DERMATOLOGY JONITH Y BREADON MD LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AESTHETIC DERMATOLOGY JONITH Y BREADON MD LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
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Provider Other Name Prefix Text:
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NPI Number Information

NPI Number:
1225163967
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1009 W FULTON MARKET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60607-1222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-733-2492
Provider Business Mailing Address Fax Number:
312-733-2498

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1009 W FULTON MARKET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60607-1222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-733-2492
Provider Business Practice Location Address Fax Number:
312-733-2498
Provider Enumeration Date:
02/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BREADON
Authorized Official First Name:
JONITH
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER-PROPRIETOR-HEAD PHYSICIAN
Authorized Official Telephone Number:
312-733-2498

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 31602551 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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