Provider Demographics
NPI:1376780098
Name:THE DERMATOLOGY CENTER PLLC
Entity Type:Organization
Organization Name:THE DERMATOLOGY CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:STITES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-242-6647
Mailing Address - Street 1:7900 DALLAS ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5690
Mailing Address - Country:US
Mailing Address - Phone:479-242-6647
Mailing Address - Fax:479-250-0505
Practice Address - Street 1:7900 DALLAS STREET
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5690
Practice Address - Country:US
Practice Address - Phone:479-242-6647
Practice Address - Fax:479-250-0505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-16
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-2778207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR176760002Medicaid
AR5L844Medicare PIN