Provider Demographics
NPI:1598176554
Name:PHILADELPHIA CENTER FOR DERMATOLOGY, PC
Entity Type:Organization
Organization Name:PHILADELPHIA CENTER FOR DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ATSUKO
Authorized Official - Middle Name:
Authorized Official - Last Name:KODAMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:267-538-5045
Mailing Address - Street 1:8400 ROOSEVELT BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-2081
Mailing Address - Country:US
Mailing Address - Phone:267-538-5045
Mailing Address - Fax:267-538-2153
Practice Address - Street 1:8400 ROOSEVELT BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-2081
Practice Address - Country:US
Practice Address - Phone:267-538-5045
Practice Address - Fax:267-538-2153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-13
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD440883207ND0900X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA357429Medicare PIN