1528404886 NPI number — INTEGRATED DERMATOLOGY OF COLUMBUS LLC

Table of content: (NPI 1528404886)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528404886 NPI number — INTEGRATED DERMATOLOGY OF COLUMBUS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRATED DERMATOLOGY OF COLUMBUS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
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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:
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NPI Number Information

NPI Number:
1528404886
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4700 EXCHANGE CT STE 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33431-4450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-314-2000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 TAYLOR STATION RD
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43213-4440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-863-3222
Provider Business Practice Location Address Fax Number:
614-863-4450
Provider Enumeration Date:
05/14/2013

Additional Information

Authorized Official

Authorized Official Last Name:
QUEEN
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
561-314-2000

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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