Provider Demographics
NPI:1750470175
Name:THE CENTER FOR ADVANCED DERMATOLOGY, P.C.
Entity type:Organization
Organization Name:THE CENTER FOR ADVANCED DERMATOLOGY, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ADRIANA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:HOLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-867-7546
Mailing Address - Street 1:4530 E SHEA BLVD.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028
Mailing Address - Country:US
Mailing Address - Phone:602-867-7546
Mailing Address - Fax:602-971-0065
Practice Address - Street 1:4530 E SHEA BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028
Practice Address - Country:US
Practice Address - Phone:602-867-7546
Practice Address - Fax:602-971-0065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20919174400000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ20919Medicare UPIN