Provider Demographics
NPI:1083200794
Name:ANNE ARUNDEL DERMATOLOGY AFFILIATES PC
Entity Type:Organization
Organization Name:ANNE ARUNDEL DERMATOLOGY AFFILIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:
Authorized Official - Last Name:DEAVERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-384-9311
Mailing Address - Street 1:1306 CONCOURSE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:LINTHICUM
Mailing Address - State:MD
Mailing Address - Zip Code:21090-1033
Mailing Address - Country:US
Mailing Address - Phone:410-384-9311
Mailing Address - Fax:410-384-9433
Practice Address - Street 1:54 SCOTT ADAM RD STE 301
Practice Address - Street 2:
Practice Address - City:HUNT VALLEY
Practice Address - State:MD
Practice Address - Zip Code:21030-3360
Practice Address - Country:US
Practice Address - Phone:443-351-3376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANNE ARUNDEL DERMATOLOGY, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Multi-Specialty