1053771048 NPI number — DERMONE DERMATOLOGY ASSOCIATES OF THE GARDEN STATE, PC

Table of content: (NPI 1053771048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053771048 NPI number — DERMONE DERMATOLOGY ASSOCIATES OF THE GARDEN STATE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMONE DERMATOLOGY ASSOCIATES OF THE GARDEN STATE, PC
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:
1053771048
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
FOUR TOWER BRIDGE, 200 BARR HARBOR DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
WEST CONSHOHOCKEN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19428-1518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
848-240-2812
Provider Business Mailing Address Fax Number:
732-731-6135

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 IRON BRIDGE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREEHOLD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-337-6663
Provider Business Practice Location Address Fax Number:
732-731-6135
Provider Enumeration Date:
03/03/2016

Additional Information

Authorized Official

Authorized Official Last Name:
PETRICK
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CHIEF FINANCIAL & ADMIN. OFFICER
Authorized Official Telephone Number:
484-240-6550

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ND0900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207NP0225X ; 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: 207ND0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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