Basic Information
| Provider Information | |||||||||
| NPI: | 1407962210 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERMATOLOGY CENTERS INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 DAVIS STUART ROAD | ||||||||
| Address2: | |||||||||
| City: | RONCEVERTE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 24970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046457546 | ||||||||
| FaxNumber: | 3046457547 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 DAVIS STUART ROAD | ||||||||
| Address2: | |||||||||
| City: | RONCEVERTE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 24970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046457546 | ||||||||
| FaxNumber: | 3046457547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 08/01/2007 | ||||||||
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| AuthorizedOfficialLastName: | KARRS | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3046457546 | ||||||||
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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 | 207N00000X | 14295 | WV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 0009350000 | 05 | WV | MEDICAID |