Provider Demographics
NPI:1508197112
Name:OHIO SKIN CANCER INSTITUTE LLC
Entity type:Organization
Organization Name:OHIO SKIN CANCER INSTITUTE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARISA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAVITSKIY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-585-9900
Mailing Address - Street 1:5040 FOREST DR STE 200
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:OH
Mailing Address - Zip Code:43054-8166
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5040 FOREST DR STE 200
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:OH
Practice Address - Zip Code:43054-8166
Practice Address - Country:US
Practice Address - Phone:614-585-9900
Practice Address - Fax:614-585-9999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-21
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2901560Medicaid