Basic Information
| Provider Information | |||||||||
| NPI: | 1083957906 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BINGHAM DERMATOLOGY GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2855 E BROWN RD | ||||||||
| Address2: | SUITE 22 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852134213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1111111111 | ||||||||
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| Address1: | 2855 E BROWN RD | ||||||||
| Address2: | SUITE 22 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852134213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1111111111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2013 | ||||||||
| LastUpdateDate: | 03/28/2013 | ||||||||
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| AuthorizedOfficialLastName: | BINGHAM | ||||||||
| AuthorizedOfficialFirstName: | JEREMY | ||||||||
| AuthorizedOfficialMiddleName: | KEMPTON | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER / MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 1111111111 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 5198 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.