Provider Demographics
NPI:1629279310
Name:DERMATOLOGY AND MOHS SURGERY CENTER PC
Entity Type:Organization
Organization Name:DERMATOLOGY AND MOHS SURGERY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:PETERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-351-3376
Mailing Address - Street 1:1306 CONCOURSE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:LINTHICUM HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:21090-1033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2003 LOWER STATE RD BLDG 200
Practice Address - Street 2:
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18901-2622
Practice Address - Country:US
Practice Address - Phone:215-345-6647
Practice Address - Fax:215-345-0460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD074439L207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty