Provider Demographics
NPI:1073682142
Name:NORTH BAY DERMATOLOGY ASSOC
Entity Type:Organization
Organization Name:NORTH BAY DERMATOLOGY ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-763-6816
Mailing Address - Street 1:106 LYNCH CREEK WAY
Mailing Address - Street 2:#8
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954
Mailing Address - Country:US
Mailing Address - Phone:707-763-6816
Mailing Address - Fax:707-763-1730
Practice Address - Street 1:106 LYNCH CREEK WAY
Practice Address - Street 2:#8
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954
Practice Address - Country:US
Practice Address - Phone:707-763-6816
Practice Address - Fax:707-763-1730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ34981ZMedicare ID - Type Unspecified