Provider Demographics
NPI:1326025735
Name:FREDERICKSBURG DERMATOLOGIC ASSOCIATES PC
Entity Type:Organization
Organization Name:FREDERICKSBURG DERMATOLOGIC ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PEGGIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-371-3115
Mailing Address - Street 1:1300 THORNTON ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-4654
Mailing Address - Country:US
Mailing Address - Phone:540-371-3115
Mailing Address - Fax:540-372-9860
Practice Address - Street 1:1300 THORNTON ST
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4654
Practice Address - Country:US
Practice Address - Phone:540-371-3115
Practice Address - Fax:540-372-9860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VI=========OtherEIN