Basic Information
| Provider Information | |||||||||
| NPI: | 1437644341 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VIRGINIA DERMATOLOGY & SKIN SURGERY CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VIRGINIA DERMATOLOGY & SKIN SURGERY CENTER LAB | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1985 JEFFERSON DAVIS HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403736647 | ||||||||
| FaxNumber: | 5404791656 | ||||||||
| Practice Location | |||||||||
| Address1: | 1985 JEFFERSON DAVIS HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403736647 | ||||||||
| FaxNumber: | 5404791656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2018 | ||||||||
| LastUpdateDate: | 06/25/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EID | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5403736647 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VIRGINIA DERMATOLOGY AND SKIN SURGERY CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0008X | Y | 193400000X SINGLE SPECIALTY GROUP |
No ID Information.