Provider Demographics
NPI:1669482105
Name:FAMILY DERMATOLOGY OF PENNSYLVANIA, PC
Entity Type:Organization
Organization Name:FAMILY DERMATOLOGY OF PENNSYLVANIA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:M
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-483-3666
Mailing Address - Street 1:629 BEAVER RUIN RD NW
Mailing Address - Street 2:SUITE B
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3468
Mailing Address - Country:US
Mailing Address - Phone:770-921-4300
Mailing Address - Fax:770-381-6451
Practice Address - Street 1:6 HEARTHSTONE CT
Practice Address - Street 2:SUITE 101
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19606-3065
Practice Address - Country:US
Practice Address - Phone:610-779-7773
Practice Address - Fax:610-779-7775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102386765-0001Medicaid
PA107590Medicare PIN
MD221002Medicare PIN
NJ196380Medicare PIN
FLEP581AMedicare PIN
MD215315Medicare PIN
PA107593Medicare PIN
PADF5493Medicare PIN
MA0020828Medicare PIN