1376733162 NPI number — TRI COUNTY DERMATOLOGY INC

Table of content: (NPI 1376733162)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376733162 NPI number — TRI COUNTY DERMATOLOGY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI COUNTY DERMATOLOGY INC
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:
1376733162
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4240 MUNSON ST NW STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44718-2978
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-492-2327
Provider Business Mailing Address Fax Number:
330-492-0953

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 DEVON PLACE
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
KENT
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-929-9009
Provider Business Practice Location Address Fax Number:
330-929-6264
Provider Enumeration Date:
07/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WIKAS
Authorized Official First Name:
SCHIELD
Authorized Official Middle Name:
MARTIN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
330-492-2327

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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