Provider Demographics
NPI:1083685739
Name:CENTRAL MONTGOMERY DERMATOLOGY
Entity Type:Organization
Organization Name:CENTRAL MONTGOMERY DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIRFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-361-5030
Mailing Address - Street 1:1003 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-5338
Mailing Address - Country:US
Mailing Address - Phone:215-361-5030
Mailing Address - Fax:215-412-3587
Practice Address - Street 1:1003 S BROAD ST
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-5338
Practice Address - Country:US
Practice Address - Phone:215-361-5030
Practice Address - Fax:215-412-3587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
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
PA057196Medicare ID - Type Unspecified