Provider Demographics
NPI:1356376917
Name:FAIRLAWN DERMATOLOGY, LLC
Entity type:Organization
Organization Name:FAIRLAWN DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:W
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:330-864-9000
Mailing Address - Street 1:55 MERZ BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-2895
Mailing Address - Country:US
Mailing Address - Phone:330-864-9000
Mailing Address - Fax:330-864-9004
Practice Address - Street 1:55 MERZ BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-2895
Practice Address - Country:US
Practice Address - Phone:330-864-9000
Practice Address - Fax:330-864-9004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH8780261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty