Provider Demographics
NPI:1164416301
Name:ADVANCED DERMATOLOGY LASER AND MOHS SURGERY CENTER
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY LASER AND MOHS SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROLD
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:GRAFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-232-6446
Mailing Address - Street 1:240 E GROVE ST
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07090-1687
Mailing Address - Country:US
Mailing Address - Phone:908-232-6446
Mailing Address - Fax:908-232-6447
Practice Address - Street 1:240 E GROVE ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-1687
Practice Address - Country:US
Practice Address - Phone:908-232-6446
Practice Address - Fax:908-232-6447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Not Answered207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
Not Answered207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ076785Medicare ID - Type Unspecified