Provider Demographics
NPI:1134615206
Name:CONCIERGE DERMATOLOGY MANAGEMENT, LLC
Entity type:Organization
Organization Name:CONCIERGE DERMATOLOGY MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. PROVIDER RELATIONS REP
Authorized Official - Prefix:
Authorized Official - First Name:LORA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:682-459-3629
Mailing Address - Street 1:5825 EDWARDS RANCH RD STE 201
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4122
Mailing Address - Country:US
Mailing Address - Phone:817-205-3075
Mailing Address - Fax:
Practice Address - Street 1:203 WALLS DR STE 100
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-7029
Practice Address - Country:US
Practice Address - Phone:817-205-3075
Practice Address - Fax:817-641-3355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0518207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty