Provider Demographics
NPI:1942357454
Name:PENNSYLVANIA DERMATOLOGY GROUP, P.C.
Entity Type:Organization
Organization Name:PENNSYLVANIA DERMATOLOGY GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CHACHKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD424579
Authorized Official - Phone:215-947-7500
Mailing Address - Street 1:2301 HUNTINGDON PIKE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HUNTINGDON VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19006-6130
Mailing Address - Country:US
Mailing Address - Phone:215-947-7500
Mailing Address - Fax:215-947-7501
Practice Address - Street 1:2301 HUNTINGDON PIKE
Practice Address - Street 2:SUITE 202
Practice Address - City:HUNTINGDON VALLEY
Practice Address - State:PA
Practice Address - Zip Code:19006-6130
Practice Address - Country:US
Practice Address - Phone:215-947-7500
Practice Address - Fax:215-947-7501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0073470000OtherKEYSTONE
PA123121OtherAETNA INDIVIDUAL #
PA969482OtherAETNA GROUP #
PA1578646899OtherINDIVIDUAL NPI
PA969482OtherAETNA GROUP #
PAC63253Medicare UPIN