1114971074 NPI number — MT. LEBANON DERMATOLOGY, PC

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 1114971074 NPI number — MT. LEBANON DERMATOLOGY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MT. LEBANON DERMATOLOGY, 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:
1114971074
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
607 WASHINGTON RD
Provider Second Line Business Mailing Address:
LOWER LEVEL
Provider Business Mailing Address City Name:
PITTSBURGH
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15228-1903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
412-440-0270
Provider Business Mailing Address Fax Number:
412-440-0271

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
607 WASHINGTON RD
Provider Second Line Business Practice Location Address:
LOWER LEVEL
Provider Business Practice Location Address City Name:
PITTSBURGH
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15228-1903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-440-0270
Provider Business Practice Location Address Fax Number:
412-440-0271
Provider Enumeration Date:
05/22/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FUNT
Authorized Official First Name:
JACQUELINE
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
CORPORATE SECRETARY
Authorized Official Telephone Number:
412-440-0270

Provider Taxonomy Codes

  • Taxonomy code: 207NS0135X , 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)