Provider Demographics
NPI:1215007455
Name:MADISON DERMATOLOGY LLC
Entity Type:Organization
Organization Name:MADISON DERMATOLOGY LLC
Other - Org Name:SKIN SOLUTIONS LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:GABRIEL
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-265-9191
Mailing Address - Street 1:122 DEMAREE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-4622
Mailing Address - Country:US
Mailing Address - Phone:812-265-9191
Mailing Address - Fax:812-265-1050
Practice Address - Street 1:122 DEMAREE DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-4622
Practice Address - Country:US
Practice Address - Phone:812-265-9191
Practice Address - Fax:812-265-1050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN15D1048313OtherCLIA FOR COLUMBUS LOCATIO
IN15D0952312OtherCLIA FOR MADISON LOCATION
IN15D1048313OtherCLIA FOR COLUMBUS LOCATIO