Provider Demographics
NPI:1649361643
Name:21ST CENTURY DERMATOLOGY,LLC
Entity type:Organization
Organization Name:21ST CENTURY DERMATOLOGY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-445-8786
Mailing Address - Street 1:1 WEST RIDGEWOOD AVENUE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-2361
Mailing Address - Country:US
Mailing Address - Phone:201-445-8786
Mailing Address - Fax:201-445-8811
Practice Address - Street 1:1 WEST RIDGEWOOD AVENUE
Practice Address - Street 2:SUITE 305
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-2359
Practice Address - Country:US
Practice Address - Phone:201-445-8786
Practice Address - Fax:201-445-8811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ052171Medicare PIN