Basic Information
| Provider Information | |||||||||
| NPI: | 1134483274 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CITY DERMATOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3260 TILLMAN DR | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | BENSALEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190202029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2673320321 | ||||||||
| FaxNumber: | 2673320323 | ||||||||
| Practice Location | |||||||||
| Address1: | 3260 TILLMAN DR | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | BENSALEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190202029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2673320321 | ||||||||
| FaxNumber: | 2673320323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2012 | ||||||||
| LastUpdateDate: | 10/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | AMIR | ||||||||
| AuthorizedOfficialFirstName: | IMRAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2153058834 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | MD420353 | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 103088884-0001 | 05 | PA | MEDICAID |