Provider Demographics
NPI:1043409303
Name:MIDWEST DERMATOLOGY CENTRE LLC
Entity Type:Organization
Organization Name:MIDWEST DERMATOLOGY CENTRE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:WOOFTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-587-0778
Mailing Address - Street 1:1959 NEWARK GRANVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GRANVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43023-9171
Mailing Address - Country:US
Mailing Address - Phone:740-587-0778
Mailing Address - Fax:740-587-0601
Practice Address - Street 1:1959 NEWARK GRANVILLE RD
Practice Address - Street 2:
Practice Address - City:GRANVILLE
Practice Address - State:OH
Practice Address - Zip Code:43023-9171
Practice Address - Country:US
Practice Address - Phone:740-587-0778
Practice Address - Fax:740-587-0601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9325611Medicare PIN