Provider Demographics
NPI:1831296888
Name:TOTAL SKIN & BEAUTY DERMATOLOGY CENTER, PC
Entity Type:Organization
Organization Name:TOTAL SKIN & BEAUTY DERMATOLOGY CENTER, PC
Other - Org Name:TOTAL DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:CHANDRA
Authorized Official - Middle Name:BELLE
Authorized Official - Last Name:RODIVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-380-6117
Mailing Address - Street 1:2100 16TH AVE S
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-5021
Mailing Address - Country:US
Mailing Address - Phone:205-933-0987
Mailing Address - Fax:205-930-1758
Practice Address - Street 1:1927 1ST AVE N STE 200
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35203-4050
Practice Address - Country:US
Practice Address - Phone:059-330-9872
Practice Address - Fax:205-930-1758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN132590024OtherMEDICARE PTAN
ALCM6550OtherRAILROAD MCR