Provider Demographics
NPI:1598982704
Name:DERMATOLOGY LASER SURGERY CENTER INC
Entity Type:Organization
Organization Name:DERMATOLOGY LASER SURGERY CENTER INC
Other - Org Name:DR PALMER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-433-4922
Mailing Address - Street 1:3723 HAUCK RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45241
Mailing Address - Country:US
Mailing Address - Phone:513-769-8346
Mailing Address - Fax:937-433-6520
Practice Address - Street 1:6720 LOOP RD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-2161
Practice Address - Country:US
Practice Address - Phone:937-433-4922
Practice Address - Fax:937-433-6520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35043176207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH402741848001OtherMEDICAL MUTUAL
OHDE181759OtherMEDIGAP NUMBER
OH15317OtherANTHEM
OH15317OtherANTHEM
OH=========OtherAETNA
OH=========OtherCIGNA
OH=========OtherCORPORATION NUMBER
OH=========OtherAETNA