Provider Demographics
NPI:1073528733
Name:ADVANCED DERMATOLOGY OF NORTH CENTRAL OHIO INC
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY OF NORTH CENTRAL OHIO INC
Other - Org Name:ADVANCED DERMATOLOGY OF NORTH CENTRAL OHIO INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRIST
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:TICORAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-756-1600
Mailing Address - Street 1:770 BALGREEN DR.
Mailing Address - Street 2:STE. 201
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-4106
Mailing Address - Country:US
Mailing Address - Phone:419-756-1600
Mailing Address - Fax:419-775-1196
Practice Address - Street 1:770 BALGREEN DR
Practice Address - Street 2:STE 201
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-4106
Practice Address - Country:US
Practice Address - Phone:419-756-1600
Practice Address - Fax:419-775-1196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207N00000X, 207NS0135X
OH35063717T207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2251316Medicaid
OHCH7642Medicare PIN
OH9315311Medicare PIN