Provider Demographics
NPI:1821118613
Name:SKIN PC
Entity Type:Organization
Organization Name:SKIN PC
Other - Org Name:RESTON DERMATOLOGY COSMETIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-766-2220
Mailing Address - Street 1:1800 TOWN CENTER DR STE 212
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-3238
Mailing Address - Country:US
Mailing Address - Phone:703-766-2220
Mailing Address - Fax:571-323-1486
Practice Address - Street 1:1800 TOWN CENTER DR STE 212
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3238
Practice Address - Country:US
Practice Address - Phone:703-766-2220
Practice Address - Fax:571-323-1486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2023-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG01227Medicare ID - Type UnspecifiedMEDICARE ID
VAH28213Medicare UPIN