Provider Demographics
NPI:1942340542
Name:CENTER FOR DERMATOLOGY, LASER AND COSMETIC SURGERY LLC
Entity Type:Organization
Organization Name:CENTER FOR DERMATOLOGY, LASER AND COSMETIC SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:
Authorized Official - Last Name:FARBER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-676-2464
Mailing Address - Street 1:822 MONTGOMERY AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NARBERTH
Mailing Address - State:PA
Mailing Address - Zip Code:19072-1937
Mailing Address - Country:US
Mailing Address - Phone:610-664-4433
Mailing Address - Fax:610-664-5290
Practice Address - Street 1:9892 BUSTLETON AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-2184
Practice Address - Country:US
Practice Address - Phone:215-676-2464
Practice Address - Fax:215-676-5536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD032429E207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101436700001Medicaid
PACE1764878OtherBLUE SHIELD
PA095922OtherMEDICARE PTAN
PA2430802000OtherINDEPENDENCE BLUE CROSS
PA2430802000OtherINDEPENDENCE BLUE CROSS