Basic Information
| Provider Information | |||||||||
| NPI: | 1952413080 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHARLES COUNTY DERMATOLOGY ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O BOX 791011 | ||||||||
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| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018431600 | ||||||||
| FaxNumber: | 3016454734 | ||||||||
| Practice Location | |||||||||
| Address1: | 4225 ALTAMONT PLACE | ||||||||
| Address2: | UNIT 3 | ||||||||
| City: | WHITE PLAINS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018431600 | ||||||||
| FaxNumber: | 3016454734 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 03/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | BERGER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 3018431600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD PA | ||||||||
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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 | 415P | 01 | MD | MEDICARE GROUP | OTHER |