1609239847 NPI number — COMMONWEALTH DERMATOLOGY, P.C.

Table of content: (NPI 1609239847)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609239847 NPI number — COMMONWEALTH DERMATOLOGY, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMONWEALTH DERMATOLOGY, P.C.
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:
1609239847
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3055 WASHINGTON RD
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
MC MURRAY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15317-3279
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-260-5424
Provider Business Mailing Address Fax Number:
724-260-5425

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3055 WASHINGTON RD
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
MC MURRAY
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15317-3279
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-260-5424
Provider Business Practice Location Address Fax Number:
724-260-5425
Provider Enumeration Date:
04/04/2016

Additional Information

Authorized Official

Authorized Official Last Name:
PETRIE
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
SHANE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
336-403-5331

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  MD438908 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ND0101X , with the licence number: MD438908 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 103091870-0001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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