Provider Demographics
NPI:1386868438
Name:DERMATOLOGY OF CAPE COD, PC
Entity Type:Organization
Organization Name:DERMATOLOGY OF CAPE COD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LISKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-563-2550
Mailing Address - Street 1:37 EDGERTON DR
Mailing Address - Street 2:
Mailing Address - City:NORTH FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02556-2821
Mailing Address - Country:US
Mailing Address - Phone:508-563-2550
Mailing Address - Fax:508-563-2570
Practice Address - Street 1:37 EDGERTON DR
Practice Address - Street 2:
Practice Address - City:NORTH FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02556-2821
Practice Address - Country:US
Practice Address - Phone:508-563-2550
Practice Address - Fax:508-563-2570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA695562OtherTUFTS
MAM18770OtherBC BS
MA9733540Medicaid
MA4190OtherHARVARD PILGRIM
MAM21470Medicare ID - Type Unspecified