Provider Demographics
NPI:1730133455
Name:MITCHELL LESLIE BRESSACK
Entity Type:Organization
Organization Name:MITCHELL LESLIE BRESSACK
Other - Org Name:DERMATOLOGY CENTER OF NW INDIANA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRESSACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-662-8822
Mailing Address - Street 1:70 WEST 94TH PLACE
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-1710
Mailing Address - Country:US
Mailing Address - Phone:219-662-8822
Mailing Address - Fax:219-662-8833
Practice Address - Street 1:70 WEST 94TH PLACE
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-1710
Practice Address - Country:US
Practice Address - Phone:219-662-8822
Practice Address - Fax:219-662-8833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN234710Medicare PIN
INCB8685Medicare PIN