Provider Demographics
NPI:1588859946
Name:DERMATOLOGY SURGICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:DERMATOLOGY SURGICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:CHARTIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-676-1900
Mailing Address - Street 1:499 FARMINGTON AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1933
Mailing Address - Country:US
Mailing Address - Phone:860-676-1900
Mailing Address - Fax:860-409-0602
Practice Address - Street 1:499 FARMINGTON AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1933
Practice Address - Country:US
Practice Address - Phone:860-676-1900
Practice Address - Fax:860-409-0602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039399207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT9835320OtherCIGNA
CT2V5362OtherHEALTH NET
CT039399OtherCONNECTICARE
CT2000464OtherUNITED HEALTH CARE
CTC03194OtherMEDICARE GROUP NUMBER
CTP2392298OtherOXFORD
CT3672726OtherAETNA
CT010039399CT02OtherANTHEM BLUE CROSS/BLUE SH
CT039399OtherCONNECTICARE
CT010039399CT02OtherANTHEM BLUE CROSS/BLUE SH