Provider Demographics
NPI:1750347480
Name:NORTHCOAST DERMATOLOGY ASSOCIATES, INC.
Entity type:Organization
Organization Name:NORTHCOAST DERMATOLOGY ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:SUTTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-524-4009
Mailing Address - Street 1:6701 ROCKSIDE RD
Mailing Address - Street 2:SUITE 330
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2358
Mailing Address - Country:US
Mailing Address - Phone:216-524-4009
Mailing Address - Fax:216-524-7933
Practice Address - Street 1:6701 ROCKSIDE RD
Practice Address - Street 2:SUITE 330
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2358
Practice Address - Country:US
Practice Address - Phone:216-524-4009
Practice Address - Fax:216-524-7933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0289727Medicaid
OHCD6030OtherRAILROAD MEDICARE SAG
OH0271423Medicaid
OHCC5264OtherRAILROAD MEDICARE-INDEP
OHCC5264OtherRAILROAD MEDICARE-INDEP
OH9284652Medicare PIN