1750400230 NPI number — MIDTOWN DERMATOLOGY LLC

Table of content: (NPI 1750400230)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750400230 NPI number — MIDTOWN DERMATOLOGY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDTOWN DERMATOLOGY LLC
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:
1750400230
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2424 E. 21ST STREET
Provider Second Line Business Mailing Address:
SUITE 340
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-728-3100
Provider Business Mailing Address Fax Number:
918-728-3376

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2424 E. 21ST STREET
Provider Second Line Business Practice Location Address:
SUITE 340
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-728-3100
Provider Business Practice Location Address Fax Number:
918-728-3376
Provider Enumeration Date:
03/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TERHUNE
Authorized Official First Name:
GRETA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
918-743-4046

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  18895 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: CH7333 . This is a "RAILROAD MEDICARE - PALMETTO GBA" identifier . This identifiers is of the category "OTHER".




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