Provider Demographics
NPI:1669444139
Name:FAMILY DERMATOLOGY OF THE LEHIGH VALLEY PC
Entity Type:Organization
Organization Name:FAMILY DERMATOLOGY OF THE LEHIGH VALLEY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:KUCIRKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-769-4200
Mailing Address - Street 1:4110 INDEPENDENCE DR
Mailing Address - Street 2:STE 300
Mailing Address - City:SCHNECKSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18078
Mailing Address - Country:US
Mailing Address - Phone:610-769-4200
Mailing Address - Fax:610-769-4204
Practice Address - Street 1:4110 INDEPENDENCE DR
Practice Address - Street 2:STE 300
Practice Address - City:SCHNECKSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18078
Practice Address - Country:US
Practice Address - Phone:610-769-4200
Practice Address - Fax:610-769-4204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD031979E207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1580638OtherBLUE SHIELD
PA50029439OtherBLUE CROSS
PA1580638OtherBLUE SHIELD
PA076475Medicare ID - Type Unspecified