Provider Demographics
NPI:1376721373
Name:ASSOCIATED DERMATOLOGY
Entity Type:Organization
Organization Name:ASSOCIATED DERMATOLOGY
Other - Org Name:DR. MARTIN BLACKWELL
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:973-300-0555
Mailing Address - Street 1:136 WOODSIDE AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07860
Mailing Address - Country:US
Mailing Address - Phone:973-300-0555
Mailing Address - Fax:973-300-0052
Practice Address - Street 1:136 WOODSIDE AVE
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NJ
Practice Address - Zip Code:07860
Practice Address - Country:US
Practice Address - Phone:973-300-0555
Practice Address - Fax:973-300-0052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-01
Last Update Date:2008-11-12
Deactivation Date:2008-07-11
Deactivation Code:
Reactivation Date:2008-11-12
Provider Licenses
StateLicense IDTaxonomies
NJ25MB05321100207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE27347Medicare UPIN