Provider Demographics
NPI:1821265943
Name:WEST DERMATOLOGY OF PENNSYLVANIA A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:WEST DERMATOLOGY OF PENNSYLVANIA A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:J. ROBERT WEST, M.D., INC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-335-8649
Mailing Address - Street 1:PO BOX 2199
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-0721
Mailing Address - Country:US
Mailing Address - Phone:909-335-8649
Mailing Address - Fax:909-557-1953
Practice Address - Street 1:150 W BEAU ST
Practice Address - Street 2:SUITE 308
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-4425
Practice Address - Country:US
Practice Address - Phone:724-225-1505
Practice Address - Fax:724-225-5810
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:J. ROBERT WEST, M.D., INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-08
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD432414207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMD432414OtherMEDICAL LICENSE
PADN4267OtherRAILROAD MEDICARE WEST DERM OF PA
PARU2030643OtherHIGHMARK BLUE SHIELD
PA126231Medicare PIN