Provider Demographics
NPI:1891702957
Name:ALLIANCE DERMATOLOGY & MOHS CENTER, PC
Entity Type:Organization
Organization Name:ALLIANCE DERMATOLOGY & MOHS CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:BOTTIGLIONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-971-0268
Mailing Address - Street 1:4045 E BELL RD
Mailing Address - Street 2:147
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032
Mailing Address - Country:US
Mailing Address - Phone:602-971-0268
Mailing Address - Fax:602-971-1556
Practice Address - Street 1:4045 E BELL RD
Practice Address - Street 2:147
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032
Practice Address - Country:US
Practice Address - Phone:602-971-0268
Practice Address - Fax:602-971-1556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ74888OtherPTAN