Provider Demographics
NPI:1174652325
Name:MIDWEST DERMATOLOGY, LASER & VEIN CLINIC
Entity Type:Organization
Organization Name:MIDWEST DERMATOLOGY, LASER & VEIN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GLEASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-875-2745
Mailing Address - Street 1:3006 N CO ROAD 25-A
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-1373
Mailing Address - Country:US
Mailing Address - Phone:937-335-2075
Mailing Address - Fax:937-339-0612
Practice Address - Street 1:3006 N CO ROAD 25-A
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-1373
Practice Address - Country:US
Practice Address - Phone:937-335-2075
Practice Address - Fax:937-339-0612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9367031Medicare PIN