1780052811 NPI number — DERMATOLOGISTS OF SOUTHWESTERN OHIO, LLC.

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 1780052811 NPI number — DERMATOLOGISTS OF SOUTHWESTERN OHIO, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOLOGISTS OF SOUTHWESTERN OHIO, LLC.
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:
1780052811
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5300 FAR HILLS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAYTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45429-2381
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-433-7536
Provider Business Mailing Address Fax Number:
937-433-9612

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7691 5 MILE RD
Provider Second Line Business Practice Location Address:
SUITE 312
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45230-4348
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-232-3332
Provider Business Practice Location Address Fax Number:
513-232-9635
Provider Enumeration Date:
09/06/2015

Additional Information

Authorized Official

Authorized Official Last Name:
LEPAGE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
937-433-7536

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  004150 , 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)





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