1659361418 NPI number — DERMATOLOGY CENTER PC

Table of content: (NPI 1659361418)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659361418 NPI number — DERMATOLOGY CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOLOGY CENTER PC
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:
DERMATOLOGY CENTER PC A NEW MEXICO CORPORATION
Provider Other Organization Name Type Code:
5
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:
1659361418
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2525 S TELSHOR BLVD
Provider Second Line Business Mailing Address:
BUILDING 15 SUITE 200
Provider Business Mailing Address City Name:
LAS CRUCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88011-9148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-522-3636
Provider Business Mailing Address Fax Number:
505-522-0722

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2525 S TELSHOR BLVD
Provider Second Line Business Practice Location Address:
BUILDING 15 SUITE 200
Provider Business Practice Location Address City Name:
LAS CRUCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88011-9148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-522-3636
Provider Business Practice Location Address Fax Number:
505-522-0722
Provider Enumeration Date:
10/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SEGAL
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
505-522-3636

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  95-143 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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