Provider Demographics
NPI:1386182053
Name:TDG CENTER FOR DERMATOLOGIC CARE LLC
Entity Type:Organization
Organization Name:TDG CENTER FOR DERMATOLOGIC CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:J
Authorized Official - Last Name:SAMAHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-571-2121
Mailing Address - Street 1:347 MOUNT PLEASANT AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-2744
Mailing Address - Country:US
Mailing Address - Phone:973-571-2121
Mailing Address - Fax:973-498-0569
Practice Address - Street 1:170 AVENUE AT THE CMN
Practice Address - Street 2:SUITE 2
Practice Address - City:SHREWSBURY
Practice Address - State:NJ
Practice Address - Zip Code:07702-4803
Practice Address - Country:US
Practice Address - Phone:973-571-2121
Practice Address - Fax:732-542-6392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-02
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05082700207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty