Provider Demographics
NPI:1891239083
Name:GK DERMATOLOGY SHN, LLC
Entity Type:Organization
Organization Name:GK DERMATOLOGY SHN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:KROUMPOUZOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-812-1078
Mailing Address - Street 1:541 MAIN STREET
Mailing Address - Street 2:SUITE 320
Mailing Address - City:SOUTH WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190-1845
Mailing Address - Country:US
Mailing Address - Phone:781-812-1078
Mailing Address - Fax:
Practice Address - Street 1:541 MAIN STREET
Practice Address - Street 2:SUITE 320
Practice Address - City:SOUTH WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-1845
Practice Address - Country:US
Practice Address - Phone:781-812-1078
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GK DERMATOLOGY, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-07
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA159743207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty