Provider Demographics
NPI:1609892298
Name:ADVANCED DERMATOLOGY LLC
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-859-2262
Mailing Address - Street 1:111 SALEM TPKE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-6459
Mailing Address - Country:US
Mailing Address - Phone:860-859-2262
Mailing Address - Fax:860-859-9819
Practice Address - Street 1:111 SALEM TPKE
Practice Address - Street 2:SUITE 7
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-6459
Practice Address - Country:US
Practice Address - Phone:860-859-2262
Practice Address - Fax:860-859-9819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002932163W00000X
CT038560207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTDB9913OtherMEDICARE RAILROAD
CT222316481OtherBCBS
CT004182680Medicaid
CTDB9913OtherMEDICARE RAILROAD