Provider Demographics
NPI:1336140623
Name:DERMATOLOGY ASSOCIATES INC
Entity Type:Organization
Organization Name:DERMATOLOGY ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE CLERK
Authorized Official - Prefix:MRS
Authorized Official - First Name:GRACEY
Authorized Official - Middle Name:E
Authorized Official - Last Name:AULT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-667-4499
Mailing Address - Street 1:1514 AMHERST ST
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2803
Mailing Address - Country:US
Mailing Address - Phone:540-667-4499
Mailing Address - Fax:540-722-4172
Practice Address - Street 1:1514 AMHERST ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2803
Practice Address - Country:US
Practice Address - Phone:540-667-4499
Practice Address - Fax:540-722-4172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC00014Medicare PIN
WVCG6354Medicare PIN
VA13236Medicare PIN
WV9310951Medicare PIN