Provider Demographics
NPI:1043378508
Name:ESSEX DERMATOLOGY LLC
Entity Type:Organization
Organization Name:ESSEX DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MAHER WIESE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-767-9998
Mailing Address - Street 1:20 SAYBROOK ROAD
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:CT
Mailing Address - Zip Code:06426-1401
Mailing Address - Country:US
Mailing Address - Phone:860-767-9998
Mailing Address - Fax:860-767-9161
Practice Address - Street 1:20 SAYBROOK ROAD
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:CT
Practice Address - Zip Code:06426-1401
Practice Address - Country:US
Practice Address - Phone:860-767-9998
Practice Address - Fax:860-767-9161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03091OtherMEDICARE ID - GROUP