Provider Demographics
NPI:1558549733
Name:KEYSTONE DERMATOLOGY & CENTER FOR SKIN SURGERY, LLC
Entity Type:Organization
Organization Name:KEYSTONE DERMATOLOGY & CENTER FOR SKIN SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:FULCHIERO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD, MS
Authorized Official - Phone:814-943-7546
Mailing Address - Street 1:2525 9TH AVE STE 2A
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-2014
Mailing Address - Country:US
Mailing Address - Phone:814-943-7546
Mailing Address - Fax:814-943-7544
Practice Address - Street 1:2525 9TH AVE STE 2
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-2014
Practice Address - Country:US
Practice Address - Phone:814-943-7546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-10
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD432947207N00000X, 207ND0101X, 207ND0900X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAN/AOtherN/A
PA39D1084575OtherCLIA