Provider Demographics
NPI:1396909180
Name:FAMILY DERMATOLOGY OF PENNSYLVANIA, PC
Entity type:Organization
Organization Name:FAMILY DERMATOLOGY OF PENNSYLVANIA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:M
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-483-3666
Mailing Address - Street 1:40 MORRIS AVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-3300
Mailing Address - Country:US
Mailing Address - Phone:215-519-5487
Mailing Address - Fax:
Practice Address - Street 1:426 AIRPORT RD
Practice Address - Street 2:3 BELTWAY COMMONS
Practice Address - City:HAZLE TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18202-3361
Practice Address - Country:US
Practice Address - Phone:570-454-2435
Practice Address - Fax:570-575-0104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-11
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207ND0900X, 207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA107593Medicare PIN