1073528733 NPI number — ADVANCED DERMATOLOGY OF NORTH CENTRAL OHIO INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073528733 NPI number — ADVANCED DERMATOLOGY OF NORTH CENTRAL OHIO INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED DERMATOLOGY OF NORTH CENTRAL OHIO 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:
ADVANCED DERMATOLOGY OF NORTH CENTRAL OHIO INC
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:
1073528733
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
770 BALGREEN DR.
Provider Second Line Business Mailing Address:
STE. 201
Provider Business Mailing Address City Name:
MANSFIELD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44906-4106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-756-1600
Provider Business Mailing Address Fax Number:
419-775-1196

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
770 BALGREEN DR
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
MANSFIELD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44906-4106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-756-1600
Provider Business Practice Location Address Fax Number:
419-775-1196
Provider Enumeration Date:
07/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TICORAS
Authorized Official First Name:
CHRIST
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
419-756-1600

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207NS0135X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207NS0135X , with the licence number: 35063717T , 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: 2251316 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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