Provider Demographics
NPI:1790979417
Name:ITHACA DERMATOLOGY PLLC
Entity Type:Organization
Organization Name:ITHACA DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SILVERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-256-7546
Mailing Address - Street 1:202 TAUGHANNOCK BLVD
Mailing Address - Street 2:PO BOX 366
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14851
Mailing Address - Country:US
Mailing Address - Phone:607-277-4035
Mailing Address - Fax:607-277-3888
Practice Address - Street 1:821 CLIFF STREET
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850
Practice Address - Country:US
Practice Address - Phone:607-256-7546
Practice Address - Fax:607-256-0049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY220803207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA1196Medicare UPIN
NYH34911Medicare UPIN