Provider Demographics
NPI:1801013719
Name:WESTSIDE DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:WESTSIDE DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:NEIDENBACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-574-0017
Mailing Address - Street 1:1410B JOHN B WHITE SR BLVD
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29306-3927
Mailing Address - Country:US
Mailing Address - Phone:864-574-0017
Mailing Address - Fax:864-574-6088
Practice Address - Street 1:1410B JOHN B WHITE SR BLVD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29306-3927
Practice Address - Country:US
Practice Address - Phone:864-574-0017
Practice Address - Fax:864-574-6088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16384207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5867Medicare PIN