Provider Demographics
NPI:1598056582
Name:VIRGINIA DERMATOLOGY AND SKIN SURGERY CENTER
Entity Type:Organization
Organization Name:VIRGINIA DERMATOLOGY AND SKIN SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:P
Authorized Official - Last Name:EID
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-373-6647
Mailing Address - Street 1:1985 JEFFERSON DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-6233
Mailing Address - Country:US
Mailing Address - Phone:540-373-6647
Mailing Address - Fax:540-479-1656
Practice Address - Street 1:1985 JEFFERSON DAVIS HWY
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-5298
Practice Address - Country:US
Practice Address - Phone:540-373-6647
Practice Address - Fax:540-479-1656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101249163207ND0101X
207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAA178Medicare PIN