Provider Demographics
NPI:1659361418
Name:DERMATOLOGY CENTER PC
Entity Type:Organization
Organization Name:DERMATOLOGY CENTER PC
Other - Org Name:DERMATOLOGY CENTER PC A NEW MEXICO CORPORATION
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:SEGAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-522-3636
Mailing Address - Street 1:2525 S TELSHOR BLVD
Mailing Address - Street 2:BUILDING 15 SUITE 200
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-9148
Mailing Address - Country:US
Mailing Address - Phone:505-522-3636
Mailing Address - Fax:505-522-0722
Practice Address - Street 1:2525 S TELSHOR BLVD
Practice Address - Street 2:BUILDING 15 SUITE 200
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-9148
Practice Address - Country:US
Practice Address - Phone:505-522-3636
Practice Address - Fax:505-522-0722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM95-143207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D10501Medicare UPIN
900522124Medicare ID - Type Unspecified