Provider Demographics
NPI:1568833994
Name:SCOTTSDALE DERMATOLOGY, LTD
Entity Type:Organization
Organization Name:SCOTTSDALE DERMATOLOGY, LTD
Other - Org Name:PHOENIX DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:YARBROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-945-6356
Mailing Address - Street 1:20940 N TATUM BLVD
Mailing Address - Street 2:SUITE 270
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-4265
Mailing Address - Country:US
Mailing Address - Phone:480-502-0400
Mailing Address - Fax:480-502-0432
Practice Address - Street 1:20940 N TATUM BLVD
Practice Address - Street 2:SUITE 270
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4265
Practice Address - Country:US
Practice Address - Phone:480-502-0400
Practice Address - Fax:480-502-0432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-12
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ15963207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD37881Medicare UPIN