1205993383 NPI number — PENINSULA DERMATOLOGY SKIN CANCER SURGERY CENTER, 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 1205993383 NPI number — PENINSULA DERMATOLOGY SKIN CANCER SURGERY CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENINSULA DERMATOLOGY SKIN CANCER SURGERY CENTER, 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:
DERMATOLOGY SPECIALISTS
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:
1205993383
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11844 ROCK LANDING DR STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWPORT NEWS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23606-4202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-873-0161
Provider Business Mailing Address Fax Number:
757-873-0205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
475 MCLAWS CIRCLE
Provider Second Line Business Practice Location Address:
SUITE ONE
Provider Business Practice Location Address City Name:
WILLIAMSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23185
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-259-9466
Provider Business Practice Location Address Fax Number:
757-259-7907
Provider Enumeration Date:
01/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TURKOVICH
Authorized Official First Name:
ALLISON
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
757-873-0161

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ND0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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