Basic Information
| Provider Information | |||||||||
| NPI: | 1912464157 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LUCENT DERMATOLOGY AND SKIN SURGERY CENTER CORP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7550 LUCERNE DR STE 405 | ||||||||
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| City: | MIDDLEBURG HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441306503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402348833 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2000 AUBURN DR STE 120 | ||||||||
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| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441224328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402348833 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2019 | ||||||||
| LastUpdateDate: | 02/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | CAMP | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2056126412 | ||||||||
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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 |
No ID Information.