1942340542 NPI number — CENTER FOR DERMATOLOGY, LASER AND COSMETIC SURGERY LLC

Table of content: (NPI 1942340542)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942340542 NPI number — CENTER FOR DERMATOLOGY, LASER AND COSMETIC SURGERY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTER FOR DERMATOLOGY, LASER AND COSMETIC SURGERY 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:
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Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942340542
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
822 MONTGOMERY AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
NARBERTH
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19072-1937
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-664-4433
Provider Business Mailing Address Fax Number:
610-664-5290

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9892 BUSTLETON AVE
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19115-2184
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-676-2464
Provider Business Practice Location Address Fax Number:
215-676-5536
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FARBER
Authorized Official First Name:
HAROLD
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
215-676-2464

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  MD032429E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 101436700001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CE1764878 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 095922 . This is a "MEDICARE PTAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2430802000 . This is a "INDEPENDENCE BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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