Provider Demographics
NPI:1710955323
Name:SOUTH JERSEY DERMATOLOGY ASSOCIATES, PA
Entity Type:Organization
Organization Name:SOUTH JERSEY DERMATOLOGY ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BOOTH
Authorized Official - Middle Name:H
Authorized Official - Last Name:DURHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-227-7488
Mailing Address - Street 1:900 ROUTE 168
Mailing Address - Street 2:F6
Mailing Address - City:TURNERSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-3233
Mailing Address - Country:US
Mailing Address - Phone:856-227-7488
Mailing Address - Fax:856-228-3476
Practice Address - Street 1:900 ROUTE 168
Practice Address - Street 2:F6
Practice Address - City:TURNERSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08012-3233
Practice Address - Country:US
Practice Address - Phone:856-227-7488
Practice Address - Fax:856-228-3476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-09
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03237000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC54079Medicare UPIN
405120Medicare ID - Type Unspecified