Provider Demographics
NPI:1598785016
Name:PARK DERMATOLOGY ASSOC PC
Entity Type:Organization
Organization Name:PARK DERMATOLOGY ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:M
Authorized Official - Last Name:RITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-894-5100
Mailing Address - Street 1:ONE PEARL ST
Mailing Address - Street 2:STE 2300
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301
Mailing Address - Country:US
Mailing Address - Phone:508-894-5100
Mailing Address - Fax:508-894-5111
Practice Address - Street 1:ONE PEARL ST
Practice Address - Street 2:STE 2300
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301
Practice Address - Country:US
Practice Address - Phone:508-894-5100
Practice Address - Fax:508-894-5111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9717404Medicaid
MAM14435Medicare PIN