Provider Demographics
NPI:1144211681
Name:WORCESTER DERMATOLOGY ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:WORCESTER DERMATOLOGY ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:KIXMILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-754-3823
Mailing Address - Street 1:100 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1209
Mailing Address - Country:US
Mailing Address - Phone:508-754-3823
Mailing Address - Fax:508-753-0151
Practice Address - Street 1:100 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1209
Practice Address - Country:US
Practice Address - Phone:508-754-3823
Practice Address - Fax:508-753-0151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2021-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA75849174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM17485OtherBLUE SHIELD GROUP NUMBER
MA9700340Medicaid
MA9700340Medicaid