Provider Demographics
NPI:1225020852
Name:THE DERMATOLOGY CLINIC PA
Entity Type:Organization
Organization Name:THE DERMATOLOGY CLINIC PA
Other - Org Name:THE STOUGH CLINIC OF DERMATOLOGY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER / PROVIDER / PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:S
Authorized Official - Last Name:STIBICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-623-6100
Mailing Address - Street 1:3633 CENTRAL AVE
Mailing Address - Street 2:STE N
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-6404
Mailing Address - Country:US
Mailing Address - Phone:501-623-6100
Mailing Address - Fax:501-623-6187
Practice Address - Street 1:3633 CENTRAL AVE
Practice Address - Street 2:STE N
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6404
Practice Address - Country:US
Practice Address - Phone:501-623-6100
Practice Address - Fax:501-623-6187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-19
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR120956002Medicaid
AR5B179Medicare ID - Type Unspecified
AR5B179Medicare PIN