Provider Demographics
NPI:1760658033
Name:ADVANCED DERMATOLOGY PC
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LIPPNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-326-4160
Mailing Address - Street 1:6 LOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-2810
Mailing Address - Country:US
Mailing Address - Phone:516-326-4160
Mailing Address - Fax:516-437-0482
Practice Address - Street 1:165 ROSLYN RD
Practice Address - Street 2:
Practice Address - City:ROSLYN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11577-1315
Practice Address - Country:US
Practice Address - Phone:516-625-6222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW00482Medicare PIN