Provider Demographics
NPI:1679016745
Name:BLUE ASH DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:BLUE ASH DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:B
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-770-4212
Mailing Address - Street 1:9403 KENWOOD RD
Mailing Address - Street 2:STE B100
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-6895
Mailing Address - Country:US
Mailing Address - Phone:513-891-8045
Mailing Address - Fax:513-891-8110
Practice Address - Street 1:9403 KENWOOD RD
Practice Address - Street 2:STE B100
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-6895
Practice Address - Country:US
Practice Address - Phone:513-891-8045
Practice Address - Fax:513-891-8110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-22
Last Update Date:2017-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0209139Medicaid