Provider Demographics
NPI:1609169671
Name:DERMATOLOGY CENTER OF NORTHWEST INDIANA LLC
Entity Type:Organization
Organization Name:DERMATOLOGY CENTER OF NORTHWEST INDIANA LLC
Other - Org Name:DERMATOLOGY CENTER OF NORTHWEST INDIANA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRESSACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-662-8856
Mailing Address - Street 1:70 W 94TH PL
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-1710
Mailing Address - Country:US
Mailing Address - Phone:219-662-8822
Mailing Address - Fax:219-662-8833
Practice Address - Street 1:70 W 94TH PL
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-1710
Practice Address - Country:US
Practice Address - Phone:219-662-8822
Practice Address - Fax:219-662-8833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty