Provider Demographics
NPI:1558364869
Name:DERMATOLOGY AFFILIATES MEDICAL GROUP A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:DERMATOLOGY AFFILIATES MEDICAL GROUP A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BIREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-524-9481
Mailing Address - Street 1:1324 NELSON AVE
Mailing Address - Street 2:STE B
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5341
Mailing Address - Country:US
Mailing Address - Phone:209-524-9481
Mailing Address - Fax:209-524-9486
Practice Address - Street 1:1324 NELSON AVE
Practice Address - Street 2:STE B
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5341
Practice Address - Country:US
Practice Address - Phone:209-524-9481
Practice Address - Fax:209-524-9486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA19758174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ23160ZMedicare ID - Type Unspecified