Basic Information
| Provider Information | |||||||||
| NPI: | 1831295526 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTSHORE DERMATOLOGY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 451121 | ||||||||
| Address2: | |||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441450628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408083700 | ||||||||
| FaxNumber: | 4408083675 | ||||||||
| Practice Location | |||||||||
| Address1: | 1991 CROCKER RD | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441456969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406179114 | ||||||||
| FaxNumber: | 4406179058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 06/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | ASSAF | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4406179114 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 | 2369628 | 05 | OH | MEDICAID | CK8391 | 01 | OH | RAILROAD CARE | OTHER |