1811207210 NPI number — ADVANCED DERMATOLOGY OF COOP CITY PC

Table of content: (NPI 1811207210)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811207210 NPI number — ADVANCED DERMATOLOGY OF COOP CITY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED DERMATOLOGY OF COOP CITY 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:
ADVANCED DERMATOLOGY ASSOCIATES
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:
1811207210
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 CENTRAL PARK S
Provider Second Line Business Mailing Address:
SUITE 107
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10019-1436
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-262-2500
Provider Business Mailing Address Fax Number:
212-765-3210

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 BARTOW AVE
Provider Second Line Business Practice Location Address:
SUITE 211
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10475-4614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-671-1000
Provider Business Practice Location Address Fax Number:
212-765-3210
Provider Enumeration Date:
10/19/2010

Additional Information

Authorized Official

Authorized Official Last Name:
JAEGER
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
D
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
212-262-2500

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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