Provider Demographics
NPI:1609654466
Name:LIVE OAK DERMATOLOGY PC
Entity Type:Organization
Organization Name:LIVE OAK DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KRISTYN
Authorized Official - Middle Name:
Authorized Official - Last Name:BILLINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-655-4362
Mailing Address - Street 1:PO BOX 791
Mailing Address - Street 2:
Mailing Address - City:CARNEGIE
Mailing Address - State:PA
Mailing Address - Zip Code:15106-0791
Mailing Address - Country:US
Mailing Address - Phone:412-655-4362
Mailing Address - Fax:
Practice Address - Street 1:7176 W RIDGE RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:PA
Practice Address - Zip Code:16415-2027
Practice Address - Country:US
Practice Address - Phone:814-413-7997
Practice Address - Fax:814-413-7998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAOS015047OtherSTATE LIC