Provider Demographics
NPI:1235224957
Name:DERMATOLOGY ASSOC OF CENTRAL PA, PC
Entity Type:Organization
Organization Name:DERMATOLOGY ASSOC OF CENTRAL PA, PC
Other - Org Name:DERMATOLOGY ASSOCIATES OF CENTRAL PA, PC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:FORREST
Authorized Official - Last Name:MIKESELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-238-6097
Mailing Address - Street 1:1393 N ATHERTON ST
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-2932
Mailing Address - Country:US
Mailing Address - Phone:814-238-6097
Mailing Address - Fax:814-238-5527
Practice Address - Street 1:1393 N ATHERTON ST
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-2932
Practice Address - Country:US
Practice Address - Phone:814-238-6097
Practice Address - Fax:814-238-5527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2011-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA413750OtherPA BLUE SHIELD
PA413750OtherPA BLUE SHIELD