Provider Demographics
NPI:1154487932
Name:UNIVERSITY DERMATOLOGISTS INC
Entity Type:Organization
Organization Name:UNIVERSITY DERMATOLOGISTS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-335-8638
Mailing Address - Street 1:PO BOX 74153
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44194-4153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1611 S GREEN RD
Practice Address - Street 2:SUITE 146
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44121-4128
Practice Address - Country:US
Practice Address - Phone:909-335-8638
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCB7427OtherRAILROAD MEDICARE PIN
OH9186059Medicare PIN
OH9186055Medicare PIN
OH9186053Medicare PIN
OH9186054Medicare PIN
OH9186056Medicare PIN
OH9186052Medicare PIN
OH9186058Medicare PIN