Provider Demographics
NPI:1588612816
Name:RAINCROSS MEDICAL CENTER OF DERMATOLOGY AND COSMETIC SURGERY, INC
Entity Type:Organization
Organization Name:RAINCROSS MEDICAL CENTER OF DERMATOLOGY AND COSMETIC SURGERY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:QUAN
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-682-9293
Mailing Address - Street 1:4336 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-3518
Mailing Address - Country:US
Mailing Address - Phone:951-682-9293
Mailing Address - Fax:951-682-9299
Practice Address - Street 1:4336 MARKET ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3518
Practice Address - Country:US
Practice Address - Phone:951-682-9293
Practice Address - Fax:951-682-9299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77748207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00017530OtherRAILROAD MEDICARE
CAP00017530OtherRAILROAD MEDICARE
CA=========OtherTAX ID
CAP00017530OtherRAILROAD MEDICARE