Provider Demographics
NPI:1346601333
Name:PENROSE DERMATOLOGY PLLC
Entity Type:Organization
Organization Name:PENROSE DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DERMATOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PENROSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-620-4421
Mailing Address - Street 1:1110 SOUTH AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3403
Mailing Address - Country:US
Mailing Address - Phone:917-830-1415
Mailing Address - Fax:917-830-1418
Practice Address - Street 1:1110 SOUTH AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3403
Practice Address - Country:US
Practice Address - Phone:917-830-1415
Practice Address - Fax:917-830-1418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-17
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY245597-1261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty