Provider Demographics
NPI:1356421010
Name:THE DERMATOLOGY CLINIC OF ST TAMMANY II, LLC
Entity type:Organization
Organization Name:THE DERMATOLOGY CLINIC OF ST TAMMANY II, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:KATHERINE
Authorized Official - Last Name:GRIESHABER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-893-1035
Mailing Address - Street 1:714 W 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-2422
Mailing Address - Country:US
Mailing Address - Phone:985-893-1035
Mailing Address - Fax:
Practice Address - Street 1:714 W 16TH AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-2422
Practice Address - Country:US
Practice Address - Phone:985-893-1035
Practice Address - Fax:985-893-1058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08440 52 06207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1054810Medicaid
LA5B450Medicare ID - Type Unspecified
LA1054810Medicaid