Provider Demographics
NPI:1326148701
Name:PANACEA DERMATOLOGY, PA
Entity Type:Organization
Organization Name:PANACEA DERMATOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:C
Authorized Official - Last Name:VETTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:620-431-2273
Mailing Address - Street 1:321 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHANUTE
Mailing Address - State:KS
Mailing Address - Zip Code:66720-1836
Mailing Address - Country:US
Mailing Address - Phone:620-431-2273
Mailing Address - Fax:620-431-4749
Practice Address - Street 1:321 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CHANUTE
Practice Address - State:KS
Practice Address - Zip Code:66720-1836
Practice Address - Country:US
Practice Address - Phone:620-431-2273
Practice Address - Fax:620-431-4749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IADE3179OtherRAILROAD MEDICARE
KS111207OtherBLUE CROSS BLUE SHIELD
KS111207Medicare ID - Type UnspecifiedMEDICARE GROUP