1265768972 NPI number — INSTITUTE FOR DERMATOPATHOLOGY PC

Table of content: (NPI 1265768972)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265768972 NPI number — INSTITUTE FOR DERMATOPATHOLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INSTITUTE FOR DERMATOPATHOLOGY 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:
DERMPATH DIAGNOSTICS MID ATLANTIC
Provider Other Organization Name Type Code:
5
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:
1265768972
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7111 FAIRWAY DRIVE
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
PALM BEACH GARDENS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33418-4207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-712-6265
Provider Business Mailing Address Fax Number:
561-712-7349

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11820 PARKLAWN DR
Provider Second Line Business Practice Location Address:
402
Provider Business Practice Location Address City Name:
ROCKVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20852-2529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-214-0147
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
KRAMER
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
M
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
610-550-3000

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4241029 00 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 21D2001174 . This is a "C LIA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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