Provider Demographics
NPI:1205104601
Name:DERMATOLOGIC SURGERY CENTER OF NORTHEAST OHIO INC
Entity type:Organization
Organization Name:DERMATOLOGIC SURGERY CENTER OF NORTHEAST OHIO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:POPOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-239-4350
Mailing Address - Street 1:1133 MEDINA RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256
Mailing Address - Country:US
Mailing Address - Phone:330-239-4350
Mailing Address - Fax:330-239-4584
Practice Address - Street 1:1133 MEDINA RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-0000
Practice Address - Country:US
Practice Address - Phone:330-238-4350
Practice Address - Fax:330-239-4584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35076146P207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2190785Medicaid
OH2190785Medicaid
OHPO4032241Medicare PIN