Provider Demographics
NPI:1780740498
Name:SKIN CANCER CLINIC OF SEATTLE INC PS
Entity type:Organization
Organization Name:SKIN CANCER CLINIC OF SEATTLE INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:FADER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-335-8638
Mailing Address - Street 1:PO BOX 24922
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-0922
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 NW MARKET ST
Practice Address - Street 2:SUITE 107
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-3987
Practice Address - Country:US
Practice Address - Phone:909-335-8638
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB18739Medicare UPIN