Basic Information
| Provider Information | |||||||||
| NPI: | 1598852329 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DERMATOLOGY & PLASTIC SURGERY OF NORTHERN NEW YORK PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 91 | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136010091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157824207 | ||||||||
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| Practice Location | |||||||||
| Address1: | 826 WASHINGTON STREET | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136014065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157861500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 02/18/2009 | ||||||||
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| AuthorizedOfficialLastName: | LICZNERSKI | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3157861500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | AA0167 | 01 | NY | GROUP NUMBER | OTHER |