Provider Demographics
NPI:1659675577
Name:PREMIER DERMATOLOGY A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PREMIER DERMATOLOGY A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:H
Authorized Official - Last Name:JHIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-371-8600
Mailing Address - Street 1:55 HAWTHORNE ST
Mailing Address - Street 2:SUITE 520
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94105-3906
Mailing Address - Country:US
Mailing Address - Phone:415-371-8600
Mailing Address - Fax:415-371-8603
Practice Address - Street 1:55 HAWTHORNE ST
Practice Address - Street 2:SUITE 520
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94105-3906
Practice Address - Country:US
Practice Address - Phone:415-371-8600
Practice Address - Fax:415-371-8603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-06
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70851174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherEIN