Provider Demographics
NPI:1982829495
Name:CRANBERRY SQUARE DERMATOLOGY PC
Entity Type:Organization
Organization Name:CRANBERRY SQUARE DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:KOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-394-5556
Mailing Address - Street 1:434 ROUTE 134
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:SOUTH DENNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02660-3433
Mailing Address - Country:US
Mailing Address - Phone:508-394-5556
Mailing Address - Fax:508-394-2735
Practice Address - Street 1:434 ROUTE 134
Practice Address - Street 2:SUITE 1A
Practice Address - City:SOUTH DENNIS
Practice Address - State:MA
Practice Address - Zip Code:02660-3433
Practice Address - Country:US
Practice Address - Phone:508-394-5556
Practice Address - Fax:508-394-2735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA80792174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0000M16787OtherBLUE CROSS BLUE SHIELD
MA0000M16787OtherBLUE CROSS BLUE SHIELD
MAM21255Medicare PIN