Basic Information
| Provider Information | |||||||||
| NPI: | 1508803263 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROSEVILLE DERMATOLOGY INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1211 PLEASANT GROVE BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956786971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167847546 | ||||||||
| FaxNumber: | 9167847548 | ||||||||
| Practice Location | |||||||||
| Address1: | 1211 PLEASANT GROVE BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956786971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167847546 | ||||||||
| FaxNumber: | 9167847548 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 11/09/2007 | ||||||||
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| AuthorizedOfficialLastName: | HA | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9167847546 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 00A604281 | 01 | CA | BLUE CROSS PIN | OTHER | 1898591 | 01 | CA | CIGNA PIN | OTHER |