1053417055 NPI number — DERMATOLOGY CENTER FOR CHILDREN & YOUNG ADULTS PA

Table of content: (NPI 1053417055)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053417055 NPI number — DERMATOLOGY CENTER FOR CHILDREN & YOUNG ADULTS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOLOGY CENTER FOR CHILDREN & YOUNG ADULTS PA
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:
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:
1053417055
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:
2795 PILOT KNOB RD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
EAGAN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55121-1176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-379-9999
Provider Business Mailing Address Fax Number:
651-379-9900

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2795 PILOT KNOB RD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
EAGAN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55121-1176
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-379-9999
Provider Business Practice Location Address Fax Number:
651-379-9900
Provider Enumeration Date:
09/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLOOM
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
651-379-9999

Provider Taxonomy Codes

  • Taxonomy code: 207NP0225X , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2M741DE . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 013837 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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