Provider Demographics
NPI:1558437616
Name:UNIVERSITY DERMATOLOGY ASSOCIATES
Entity Type:Organization
Organization Name:UNIVERSITY DERMATOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:HAIBACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-756-4010
Mailing Address - Street 1:229 SUMMIT ST STE 7
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:14020-1645
Mailing Address - Country:US
Mailing Address - Phone:585-344-4811
Mailing Address - Fax:585-344-4812
Practice Address - Street 1:229 SUMMIT ST STE 7
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-1645
Practice Address - Country:US
Practice Address - Phone:585-344-4811
Practice Address - Fax:585-344-4812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG0183268190OtherBLUE CHOICE GROUP NUMBER
NYG0183268190OtherBLUE CHOICE GROUP NUMBER