Provider Demographics
NPI:1669633814
Name:KING-MACEYKO DERMATOLOGY ASSOC LTD
Entity Type:Organization
Organization Name:KING-MACEYKO DERMATOLOGY ASSOC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:H
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-536-7045
Mailing Address - Street 1:350 SOUTHMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-4330
Mailing Address - Country:US
Mailing Address - Phone:814-536-7045
Mailing Address - Fax:814-539-3927
Practice Address - Street 1:223 S PLEASANT AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:SOMERSET
Practice Address - State:PA
Practice Address - Zip Code:15501
Practice Address - Country:US
Practice Address - Phone:814-443-6918
Practice Address - Fax:814-539-3927
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KING-MACEYKO DERMATOLOGY ASSOC LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA721126OtherBLUE SHIELD MEDICARE GROUP NUMBER