Provider Demographics
NPI:1275792582
Name:MEDICAL AND COSMETIC DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:MEDICAL AND COSMETIC DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SERGE
Authorized Official - Middle Name:N
Authorized Official - Last Name:KOLEV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:717-458-8401
Mailing Address - Street 1:1300 BENT CREEK BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17050-1871
Mailing Address - Country:US
Mailing Address - Phone:717-458-8401
Mailing Address - Fax:717-458-8403
Practice Address - Street 1:1300 BENT CREEK BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17050-1871
Practice Address - Country:US
Practice Address - Phone:717-458-8401
Practice Address - Fax:717-458-8403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-03
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA127291Medicare PIN