Provider Demographics
NPI:1114132867
Name:DERMATOLOGY CENTER FOR SKIN HEALTH
Entity Type:Organization
Organization Name:DERMATOLOGY CENTER FOR SKIN HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWTHORNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-225-2236
Mailing Address - Street 1:600 SUNCREST TOWN CENTRE DR STE 115
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-1873
Mailing Address - Country:US
Mailing Address - Phone:304-598-3888
Mailing Address - Fax:304-598-0564
Practice Address - Street 1:600 SUNCREST TOWN CENTRE DR STE 115
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-1873
Practice Address - Country:US
Practice Address - Phone:304-598-3888
Practice Address - Fax:304-598-0564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21247207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001722467OtherBLUE CROSS
WV3810002533Medicaid
WVWV21247AOtherHEALTH PLAN
WV3810002533Medicaid