Provider Demographics
NPI:1801819883
Name:DERMATOLOGISTS OF SOUTHWESTERN OHIO, LLC.
Entity Type:Organization
Organization Name:DERMATOLOGISTS OF SOUTHWESTERN OHIO, LLC.
Other - Org Name:DERMATOLOGISTS OF SOUTHWEST OHIO, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MACKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-433-7536
Mailing Address - Street 1:5300 FAR HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2347
Mailing Address - Country:US
Mailing Address - Phone:937-433-7536
Mailing Address - Fax:937-433-9612
Practice Address - Street 1:5300 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-2347
Practice Address - Country:US
Practice Address - Phone:937-433-7536
Practice Address - Fax:937-433-9612
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DERMATOLOGISTS OF SOUTHWESTERN OHIO, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-25
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1801819883207N00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDE9182775Medicare ID - Type Unspecified