1255497269 NPI number — ADVANCED DERMATOLOGY CARE 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 1255497269 NPI number — ADVANCED DERMATOLOGY CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED DERMATOLOGY CARE 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:
1255497269
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2318 31ST ST
Provider Second Line Business Mailing Address:
SUITE 320
Provider Business Mailing Address City Name:
ASTORIA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11105-2892
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-728-9822
Provider Business Mailing Address Fax Number:
718-728-2004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2318 31ST ST
Provider Second Line Business Practice Location Address:
SUITE 320
Provider Business Practice Location Address City Name:
ASTORIA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11105-2892
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-728-9822
Provider Business Practice Location Address Fax Number:
718-728-2004
Provider Enumeration Date:
12/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NICOLAIDES
Authorized Official First Name:
ALEXANDER
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
718-728-9822

Provider Taxonomy Codes

  • Taxonomy code: 207NS0135X , with the licence number:  212075 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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