Provider Demographics
NPI:1518964923
Name:ADVANCED DERMATOLOGY OF NEW YORK PC
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY OF NEW YORK PC
Other - Org Name:ADVANCED DERMATOLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:D
Authorized Official - Last Name:JAEGER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:212-262-2500
Mailing Address - Street 1:200 CENTRAL PARK SOUTH
Mailing Address - Street 2:STE 107
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019
Mailing Address - Country:US
Mailing Address - Phone:212-262-2500
Mailing Address - Fax:212-246-0890
Practice Address - Street 1:2100 BARTOW AVE
Practice Address - Street 2:STE 211
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-4614
Practice Address - Country:US
Practice Address - Phone:718-865-0515
Practice Address - Fax:212-246-0890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1518964923OtherNPI
1518964923OtherNPI