Provider Demographics
NPI:1255497269
Name:ADVANCED DERMATOLOGY CARE PC
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:NICOLAIDES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-728-9822
Mailing Address - Street 1:2318 31ST ST
Mailing Address - Street 2:SUITE 320
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-2892
Mailing Address - Country:US
Mailing Address - Phone:718-728-9822
Mailing Address - Fax:718-728-2004
Practice Address - Street 1:2318 31ST ST
Practice Address - Street 2:SUITE 320
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-2892
Practice Address - Country:US
Practice Address - Phone:718-728-9822
Practice Address - Fax:718-728-2004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY212075207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH37269Medicare UPIN
NY07365Medicare ID - Type UnspecifiedPROVIDER NUMBER