Provider Demographics
NPI:1609882836
Name:NORTHEAST DERMATOLOGY AND COSMETIC SURGERY CENTER
Entity Type:Organization
Organization Name:NORTHEAST DERMATOLOGY AND COSMETIC SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:BAIN
Authorized Official - Last Name:HERRON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-473-9519
Mailing Address - Street 1:925 NORTH HAMILTON ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-4566
Mailing Address - Country:US
Mailing Address - Phone:614-473-9519
Mailing Address - Fax:614-473-9543
Practice Address - Street 1:925 NORTH HAMILTON ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-4566
Practice Address - Country:US
Practice Address - Phone:614-473-9519
Practice Address - Fax:614-473-9543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35078963207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9335271Medicare PIN