Basic Information
| Provider Information | |||||||||
| NPI: | 1740655331 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERMATOLOGIC PROCEDURES OF SUFFOLK COUNTY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 510 MONTAUK HWY | ||||||||
| Address2: | |||||||||
| City: | WEST ISLIP | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117954422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166256222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 510 MONTAUK HWY | ||||||||
| Address2: | |||||||||
| City: | WEST ISLIP | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117954422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166256222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2015 | ||||||||
| LastUpdateDate: | 12/11/2015 | ||||||||
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| AuthorizedOfficialLastName: | FOX | ||||||||
| AuthorizedOfficialFirstName: | JOSHUA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5166256222 | ||||||||
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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 | 174400000X | AAAASF CERT # 5763 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 5763 | 01 | NY | AMERICAN ASSOCIATION FOR ACCREDITATION OF AMBULATORY SURGERY FACILITIES, INC. | OTHER |