Provider Demographics
NPI:1023005758
Name:DERMATOLOGY AND SKIN SURGERY APMC
Entity Type:Organization
Organization Name:DERMATOLOGY AND SKIN SURGERY APMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:S
Authorized Official - Last Name:RESNECK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-222-3278
Mailing Address - Street 1:9007 ELLERBE RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-6724
Mailing Address - Country:US
Mailing Address - Phone:318-222-3278
Mailing Address - Fax:318-424-3155
Practice Address - Street 1:9007 ELLERBE RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-6724
Practice Address - Country:US
Practice Address - Phone:318-222-3278
Practice Address - Fax:318-424-3155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-27
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CS44Medicare PIN