Provider Demographics
NPI:1790177210
Name:SHADY GROVE DERMATOLOGY
Entity Type:Organization
Organization Name:SHADY GROVE DERMATOLOGY
Other - Org Name:SHADY GROVE DERMATOLOGY, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BUSINESS CONSULTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDEE
Authorized Official - Middle Name:HALL
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-246-7417
Mailing Address - Street 1:15245 SHADY GROVE RD
Mailing Address - Street 2:SUITE 370
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3222
Mailing Address - Country:US
Mailing Address - Phone:240-246-7417
Mailing Address - Fax:
Practice Address - Street 1:15245 SHADY GROVE RD
Practice Address - Street 2:SUITE 370
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3222
Practice Address - Country:US
Practice Address - Phone:240-246-7417
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-20
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0028453174400000X
261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F47971Medicare UPIN