Provider Demographics
NPI:1639160294
Name:ADVANCED DERMATOLOGY CENTER, PC
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY CENTER, PC
Other - Org Name:RONALD JURZYK MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:S
Authorized Official - Last Name:JURZYK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-879-6171
Mailing Address - Street 1:464 WOLCOTT RD
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:CT
Mailing Address - Zip Code:06716-2626
Mailing Address - Country:US
Mailing Address - Phone:203-879-6171
Mailing Address - Fax:203-879-1191
Practice Address - Street 1:464 WOLCOTT RD
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:CT
Practice Address - Zip Code:06716-2626
Practice Address - Country:US
Practice Address - Phone:203-879-6171
Practice Address - Fax:203-879-1191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035267207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTDB0248OtherRAILROAD MEDICARE
CTDB0248OtherRAILROAD MEDICARE