Provider Demographics
NPI:1609239847
Name:COMMONWEALTH DERMATOLOGY, P.C.
Entity Type:Organization
Organization Name:COMMONWEALTH DERMATOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:PETRIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-403-5331
Mailing Address - Street 1:3055 WASHINGTON RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MC MURRAY
Mailing Address - State:PA
Mailing Address - Zip Code:15317-3279
Mailing Address - Country:US
Mailing Address - Phone:724-260-5424
Mailing Address - Fax:724-260-5425
Practice Address - Street 1:3055 WASHINGTON RD
Practice Address - Street 2:SUITE 203
Practice Address - City:MC MURRAY
Practice Address - State:PA
Practice Address - Zip Code:15317-3279
Practice Address - Country:US
Practice Address - Phone:724-260-5424
Practice Address - Fax:724-260-5425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-04
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD438908207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103091870-0001Medicaid
PA498185Medicare PIN