Provider Demographics
NPI:1235442211
Name:DERMATOLOGY & SURGERY OF SOUTHERN OHIO, INC.
Entity Type:Organization
Organization Name:DERMATOLOGY & SURGERY OF SOUTHERN OHIO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JONI
Authorized Official - Middle Name:
Authorized Official - Last Name:PROFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-858-6900
Mailing Address - Street 1:PO BOX 633048
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-3048
Mailing Address - Country:US
Mailing Address - Phone:513-858-6900
Mailing Address - Fax:513-858-6903
Practice Address - Street 1:7132 CINCINNATI DAYTON RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LIBERTY TOWNSHP
Practice Address - State:OH
Practice Address - Zip Code:45069-1775
Practice Address - Country:US
Practice Address - Phone:513-858-6900
Practice Address - Fax:513-858-6903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-20
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH035060409207N00000X, 207ND0101X, 207ND0900X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE9270061Medicare PIN