Provider Demographics
NPI:1497912893
Name:ADVANCED DERMATOLOGY AND SKIN CANCER CENTER
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY AND SKIN CANCER CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:GRONER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-965-8760
Mailing Address - Street 1:987 BOARDMAN CANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-4222
Mailing Address - Country:US
Mailing Address - Phone:330-965-8760
Mailing Address - Fax:
Practice Address - Street 1:987 BOARDMAN CANFIELD RD
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-4222
Practice Address - Country:US
Practice Address - Phone:330-965-8760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35074029291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHD369141Medicare PIN