Provider Demographics
NPI:1437595006
Name:CAPE COD DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:CAPE COD DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:WYMAN
Authorized Official - Last Name:FISKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-771-9779
Mailing Address - Street 1:134 ANSEL HALLET RD
Mailing Address - Street 2:
Mailing Address - City:W YARMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02673-2582
Mailing Address - Country:US
Mailing Address - Phone:508-771-9779
Mailing Address - Fax:508-771-4355
Practice Address - Street 1:134 ANSEL HALLET RD
Practice Address - Street 2:
Practice Address - City:W YARMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02673-2582
Practice Address - Country:US
Practice Address - Phone:508-771-9779
Practice Address - Fax:508-771-4355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-22
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA74240207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA11095135AMedicaid
LAP00429633OtherRAILROAD MEDICARE
MAJ11263OtherBCBS
MAJ11263Medicare PIN
LAP00429633OtherRAILROAD MEDICARE