Provider Demographics
NPI:1316043748
Name:KING-MACEYKO DERMATOLOGY ASSOC LTD
Entity Type:Organization
Organization Name:KING-MACEYKO DERMATOLOGY ASSOC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:H
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-536-7045
Mailing Address - Street 1:350 SOUTHMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-4330
Mailing Address - Country:US
Mailing Address - Phone:814-536-7045
Mailing Address - Fax:814-539-3927
Practice Address - Street 1:572 PHILADELPHIA ST
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701
Practice Address - Country:US
Practice Address - Phone:724-349-7720
Practice Address - Fax:724-349-8993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA723056OtherBLUE SHIELD
PA723056OtherBLUE SHIELD