Provider Demographics
NPI:1437315710
Name:AIRPORT DERMATOLOGY CLINIC PA
Entity Type:Organization
Organization Name:AIRPORT DERMATOLOGY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HARRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-484-7546
Mailing Address - Street 1:11914 ASTORIA BLVD
Mailing Address - Street 2:SUITE 340
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77089-6064
Mailing Address - Country:US
Mailing Address - Phone:281-484-7546
Mailing Address - Fax:281-484-2202
Practice Address - Street 1:11914 ASTORIA BLVD
Practice Address - Street 2:SUITE 340
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77089-6064
Practice Address - Country:US
Practice Address - Phone:281-484-7546
Practice Address - Fax:281-484-2202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-06
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD-5828261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0340473-01Medicaid
TX071445445OtherRAILROAD MEDICARE
TX071445445OtherRAILROAD MEDICARE
TXC21351Medicare UPIN