Provider Demographics
NPI:1477937480
Name:DERMASAP PLLC
Entity Type:Organization
Organization Name:DERMASAP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OM
Authorized Official - Prefix:
Authorized Official - First Name:STACI
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-472-6764
Mailing Address - Street 1:500 CONGRESS ST
Mailing Address - Street 2:B1
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-0908
Mailing Address - Country:US
Mailing Address - Phone:617-472-6764
Mailing Address - Fax:
Practice Address - Street 1:500 CONGRESS ST
Practice Address - Street 2:B1
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-0908
Practice Address - Country:US
Practice Address - Phone:617-472-6764
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-20
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA49076207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA043214763Medicaid
MA043214763Medicare UPIN
MA043214763Medicaid
043214763Medicare Oscar/Certification