Provider Demographics
NPI:1861501801
Name:PENNSYLVANIA CENTRE FOR DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:PENNSYLVANIA CENTRE FOR DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:H
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:267-519-0154
Mailing Address - Street 1:PO BOX 22624
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19110-2624
Mailing Address - Country:US
Mailing Address - Phone:267-519-0154
Mailing Address - Fax:267-519-0597
Practice Address - Street 1:822 PINE ST
Practice Address - Street 2:SUITE 2A
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-6187
Practice Address - Country:US
Practice Address - Phone:267-519-0154
Practice Address - Fax:267-519-0597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD421221207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3679792OtherAETNA
PA1607671OtherHIGHMARK BLUE SHIELD
2295672000OtherIBC
PA3679792OtherAETNA
PA1607671OtherHIGHMARK BLUE SHIELD