Provider Demographics
NPI:1639289093
Name:NORTHERN INDIANA DERMATOLOGY AND SKIN SURGERY CENTER
Entity type:Organization
Organization Name:NORTHERN INDIANA DERMATOLOGY AND SKIN SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RUCHIK
Authorized Official - Middle Name:S
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-764-3600
Mailing Address - Street 1:3190 LANCER ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-4488
Mailing Address - Country:US
Mailing Address - Phone:219-764-3600
Mailing Address - Fax:219-764-3661
Practice Address - Street 1:3190 LANCER ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-4488
Practice Address - Country:US
Practice Address - Phone:219-764-3600
Practice Address - Fax:219-764-3661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207N00000X207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000350979OtherANTHEM
IN220770Medicare ID - Type Unspecified
H97407Medicare UPIN