Provider Demographics
NPI:1891852653
Name:GRAVES DERMA CARE CENTER, PC
Entity Type:Organization
Organization Name:GRAVES DERMA CARE CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VAUGHAN
Authorized Official - Middle Name:CHANNING
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-879-2389
Mailing Address - Street 1:601 WALNUT ST
Mailing Address - Street 2:SUITE L90
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-3304
Mailing Address - Country:US
Mailing Address - Phone:215-238-1622
Mailing Address - Fax:215-238-1944
Practice Address - Street 1:601 WALNUT ST
Practice Address - Street 2:SUITE L90
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-3304
Practice Address - Country:US
Practice Address - Phone:215-238-1622
Practice Address - Fax:215-238-1944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 028158E207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009410580004Medicaid
PA0009410580004Medicaid
PAB33495Medicare UPIN