Provider Demographics
NPI:1700995974
Name:ANNAPOLIS DERMATOLOGY CENTER, PA
Entity Type:Organization
Organization Name:ANNAPOLIS DERMATOLOGY CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:G
Authorized Official - Last Name:DIAMOND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-268-3887
Mailing Address - Street 1:71 OLD MILL BOTTOM RD N
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21409-5431
Mailing Address - Country:US
Mailing Address - Phone:410-268-3877
Mailing Address - Fax:410-268-8171
Practice Address - Street 1:71 OLD MILL BOTTOM RD N
Practice Address - Street 2:SUITE 300
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21409-5431
Practice Address - Country:US
Practice Address - Phone:410-268-3877
Practice Address - Fax:410-268-8171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0053350207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDCH6676Medicaid
MDCH6676Medicaid
MD721LMedicare PIN