Provider Demographics
NPI:1578615266
Name:UNIVERSITY DERMATOLOGY CENTER PC
Entity Type:Organization
Organization Name:UNIVERSITY DERMATOLOGY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:ZEMTSOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-747-6090
Mailing Address - Street 1:3500 W PURDUE AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-6357
Mailing Address - Country:US
Mailing Address - Phone:765-747-6090
Mailing Address - Fax:765-747-5069
Practice Address - Street 1:2525 W UNIVERSITY AVE STE 402
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3409
Practice Address - Country:US
Practice Address - Phone:765-747-6090
Practice Address - Fax:765-747-5069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50003770A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9325761Medicare PIN
IN202830Medicare PIN