1174652325 NPI number — MIDWEST DERMATOLOGY, LASER & VEIN CLINIC

Table of content: (NPI 1174652325)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174652325 NPI number — MIDWEST DERMATOLOGY, LASER & VEIN CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST DERMATOLOGY, LASER & VEIN CLINIC
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:
1174652325
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3006 N CO ROAD 25-A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45373-1373
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-335-2075
Provider Business Mailing Address Fax Number:
937-339-0612

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3006 N CO ROAD 25-A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45373-1373
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-335-2075
Provider Business Practice Location Address Fax Number:
937-339-0612
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GLEASON
Authorized Official First Name:
ANGIE
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
937-875-2745

Provider Taxonomy Codes

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

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





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