Provider Demographics
NPI:1770820722
Name:BRECKSVILLE DERMATOLOGY, INC.
Entity Type:Organization
Organization Name:BRECKSVILLE DERMATOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGANN
Authorized Official - Middle Name:
Authorized Official - Last Name:POULOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-262-5520
Mailing Address - Street 1:8751 BRECKSVILLE RD STE 50
Mailing Address - Street 2:
Mailing Address - City:BRECKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44141-1950
Mailing Address - Country:US
Mailing Address - Phone:440-262-5520
Mailing Address - Fax:
Practice Address - Street 1:8751 BRECKSVILLE RD STE 50
Practice Address - Street 2:
Practice Address - City:BRECKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44141-1950
Practice Address - Country:US
Practice Address - Phone:440-262-5520
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-10
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35120088207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35120088OtherOHIO MEDICAL LICENSE