Basic Information
| Provider Information | |||||||||
| NPI: | 1285697060 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHOENIX DERMATOLOGY LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 155 | ||||||||
| Address2: | |||||||||
| City: | CHESWICK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150240155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4128261065 | ||||||||
| FaxNumber: | 4128261491 | ||||||||
| Practice Location | |||||||||
| Address1: | 4340 FULTON ROAD NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447182824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302448886 | ||||||||
| FaxNumber: | 3302448869 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 05/19/2009 | ||||||||
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| AuthorizedOfficialLastName: | CHARIF | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3302448886 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.