Provider Demographics
NPI:1578682373
Name:DERMATOLOGY LASER SURGERY CENTER INC.
Entity Type:Organization
Organization Name:DERMATOLOGY LASER SURGERY CENTER INC.
Other - Org Name:DR. PALMER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DOCTOR PRES.
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-433-4922
Mailing Address - Street 1:5 WENGER ROAD
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322
Mailing Address - Country:US
Mailing Address - Phone:937-433-4922
Mailing Address - Fax:937-433-6520
Practice Address - Street 1:5 WENGER ROAD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322
Practice Address - Country:US
Practice Address - Phone:937-832-7555
Practice Address - Fax:937-830-2227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35043172207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH402741848001OtherMEDICAL MUTUAL
OHDE181759OtherMEDIGAP NUMBER
OH=========OtherUNITED HEALTH CARE
OH=========OtherCIGNA
OH=========OtherCORPORATION NUMBER
OHDE181759OtherMEDIGAP NUMBER