Provider Demographics
NPI:1689693756
Name:WESTERN RESERVE DERMATOLOGY, INC
Entity Type:Organization
Organization Name:WESTERN RESERVE DERMATOLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:M
Authorized Official - Last Name:DURDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-378-1880
Mailing Address - Street 1:24100 CHAGRIN BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5545
Mailing Address - Country:US
Mailing Address - Phone:216-378-1880
Mailing Address - Fax:216-378-9130
Practice Address - Street 1:24100 CHAGRIN BLVD STE 400
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5545
Practice Address - Country:US
Practice Address - Phone:216-378-1880
Practice Address - Fax:216-378-9130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHWE9355141Medicare ID - Type Unspecified