Provider Demographics
NPI:1598940942
Name:DOWNTOWN DERMATOLOGY LLC
Entity Type:Organization
Organization Name:DOWNTOWN DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHARI
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS-GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-224-4566
Mailing Address - Street 1:500 E MAIN ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-5369
Mailing Address - Country:US
Mailing Address - Phone:614-224-4566
Mailing Address - Fax:614-224-6046
Practice Address - Street 1:500 E MAIN ST
Practice Address - Street 2:SUITE 310
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-4741
Practice Address - Country:US
Practice Address - Phone:614-224-4566
Practice Address - Fax:614-224-6046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-04
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35086908174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2778703Medicaid
OHI68121Medicare UPIN
OH4201611Medicare PIN