1053969287 NPI number — PREMIER PROCEDURAL DERMATOLOGY PLLC

Table of content: (NPI 1053969287)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053969287 NPI number — PREMIER PROCEDURAL DERMATOLOGY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER PROCEDURAL DERMATOLOGY PLLC
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:
1053969287
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1651 ROCK PRAIRIE RD STE 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLEGE STATION
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77845-8652
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-314-5400
Provider Business Mailing Address Fax Number:
979-704-5603

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1651 ROCK PRAIRIE RD STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLLEGE STATION
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77845-8652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-314-5400
Provider Business Practice Location Address Fax Number:
979-704-5603
Provider Enumeration Date:
08/30/2019

Additional Information

Authorized Official

Authorized Official Last Name:
AHERN
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
PROVIDER/OWNER
Authorized Official Telephone Number:
979-314-5400

Provider Taxonomy Codes

  • 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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