Provider Demographics
NPI:1477647303
Name:DERMATOLOGY CLINIC OF MUNCIE, INC.
Entity Type:Organization
Organization Name:DERMATOLOGY CLINIC OF MUNCIE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BARTHOLOME
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-288-8188
Mailing Address - Street 1:1808 W ROYALE DR
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-2243
Mailing Address - Country:US
Mailing Address - Phone:765-288-8188
Mailing Address - Fax:765-282-7242
Practice Address - Street 1:1808 W ROYALE DR
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-2243
Practice Address - Country:US
Practice Address - Phone:765-288-8188
Practice Address - Fax:765-282-7242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50001481A207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100105450Medicaid
IN204700Medicare PIN