Basic Information
| Provider Information | |||||||||
| NPI: | 1558437616 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY DERMATOLOGY ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 229 SUMMIT ST STE 7 | ||||||||
| Address2: | |||||||||
| City: | BATAVIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140201645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853444811 | ||||||||
| FaxNumber: | 5853444812 | ||||||||
| Practice Location | |||||||||
| Address1: | 229 SUMMIT ST STE 7 | ||||||||
| Address2: | |||||||||
| City: | BATAVIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140201645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853444811 | ||||||||
| FaxNumber: | 5853444812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 04/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | HAIBACH | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5857564010 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | G0183268190 | 01 | NY | BLUE CHOICE GROUP NUMBER | OTHER |