1811469760 NPI number — DERMATOLOGY AND MOHS SURGERY CENTER PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811469760 NPI number — DERMATOLOGY AND MOHS SURGERY CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOLOGY AND MOHS SURGERY CENTER 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:
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:
1811469760
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
920 LAWN AVE STE 6
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SELLERSVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18960-1560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
267-354-1440
Provider Business Mailing Address Fax Number:
267-354-1292

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
920 LAWN AVE STE 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SELLERSVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18960-1560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-354-1440
Provider Business Practice Location Address Fax Number:
267-354-1292
Provider Enumeration Date:
12/17/2018

Additional Information

Authorized Official

Authorized Official Last Name:
BREESWINE
Authorized Official First Name:
REBECCA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
215-345-6647

Provider Taxonomy Codes

  • Taxonomy code: 332900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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