Provider Demographics
NPI:1518015379
Name:MADISON AVENUE DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:MADISON AVENUE DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BEGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-795-0021
Mailing Address - Street 1:133 MADISON ST
Mailing Address - Street 2:UNIT 1 A
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-7831
Mailing Address - Country:US
Mailing Address - Phone:201-795-0021
Mailing Address - Fax:201-795-0020
Practice Address - Street 1:133 MADISON ST
Practice Address - Street 2:UNIT 1 A
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-7831
Practice Address - Country:US
Practice Address - Phone:201-795-0021
Practice Address - Fax:201-795-0020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06923300174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G89958Medicare UPIN