Provider Demographics
NPI:1023138492
Name:DERMATOLOGY AND LASER SURGERY CENTER INC
Entity type:Organization
Organization Name:DERMATOLOGY AND LASER SURGERY CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR PRES.
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-433-4922
Mailing Address - Street 1:6720 LOOP RD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-2161
Mailing Address - Country:US
Mailing Address - Phone:937-433-4922
Mailing Address - Fax:937-433-6520
Practice Address - Street 1:6720 LOOP RD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-2161
Practice Address - Country:US
Practice Address - Phone:937-433-4922
Practice Address - Fax:937-433-6520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35043172207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH402741848001OtherMEDICAL MUTUAL PROVIDER
OHDE181759OtherMEDIGAP PROVIDER NUMBER
OH=========OtherUNITED HEALTHCARE NUMBER
OH=========OtherAETNA
OH402741848001OtherMEDICAL MUTUAL PROVIDER
OH9242311Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER