Basic Information
| Provider Information | |||||||||
| NPI: | 1760617500 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MULLIGAN DERMATOLOGY, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1991 CROCKER RD | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441456969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408992300 | ||||||||
| FaxNumber: | 4406179058 | ||||||||
| Practice Location | |||||||||
| Address1: | 1991 CROCKER RD | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441456969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408992300 | ||||||||
| FaxNumber: | 4406179058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2009 | ||||||||
| LastUpdateDate: | 05/22/2009 | ||||||||
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| AuthorizedOfficialLastName: | ESSI | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4408992300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 3566003 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.