Provider Demographics
NPI:1225175441
Name:CAMELBACK DERMATOLOGY & SKIN SURGERY, INC
Entity Type:Organization
Organization Name:CAMELBACK DERMATOLOGY & SKIN SURGERY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:ROMINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-954-7546
Mailing Address - Street 1:4512 N 40TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-3600
Mailing Address - Country:US
Mailing Address - Phone:602-954-7546
Mailing Address - Fax:602-952-2941
Practice Address - Street 1:4512 N 40TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-3600
Practice Address - Country:US
Practice Address - Phone:602-954-7546
Practice Address - Fax:602-952-2941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31198207N00000X, 207ND0101X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ74336Medicare UPIN