Provider Demographics
NPI:1942336110
Name:CINCINNATI DERMATOLOGY CENTER, LLC
Entity Type:Organization
Organization Name:CINCINNATI DERMATOLOGY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MONA
Authorized Official - Middle Name:SALEM
Authorized Official - Last Name:FOAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-984-4800
Mailing Address - Street 1:7730 MONTGOMERY RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45236-4283
Mailing Address - Country:US
Mailing Address - Phone:513-984-4800
Mailing Address - Fax:
Practice Address - Street 1:7730 MONTGOMERY RD
Practice Address - Street 2:SUITE 200
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236-4283
Practice Address - Country:US
Practice Address - Phone:513-984-4800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-24
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35081463F207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2345804Medicaid
OHF04087821Medicare ID - Type Unspecified
OHH66154Medicare UPIN