1063564664 NPI number — EASTSIDE DERMATOLOGY, INC.

Table of content: (NPI 1063564664)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063564664 NPI number — EASTSIDE DERMATOLOGY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTSIDE DERMATOLOGY, INC.
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:
EASTSIDE DERMATOLOGY & SKIN CARE CENTER, EASTSIDE DERMATOLOGY OF HILLA
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063564664
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 TAYLOR STATION RD
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-863-3222
Provider Business Mailing Address Fax Number:
614-863-4450

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 TAYLOR STATION RD
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-863-3222
Provider Business Practice Location Address Fax Number:
614-863-4450
Provider Enumeration Date:
01/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PARKS
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
614-863-3222

Provider Taxonomy Codes

  • Taxonomy code: 207NS0135X , with the licence number:  35054686 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000214662 . This is a "STEPHANIE COTELL ANTHEM I" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 1215972484 . This is a "YAHNA T SMITH CNP NPI" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 1598751653 . This is a "ALAN PARKS NPI" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000118991 . This is a "ALAN PARKS ANTHEM ID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0665856 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1922093459 . This is a "STEPHANIE COTELL NPI" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2285218 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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