Provider Demographics
NPI:1780994517
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:DR
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 STE 330
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2316
Mailing Address - Country:US
Mailing Address - Phone:216-524-4009
Mailing Address - Fax:216-524-7933
Practice Address - Street 1:885 W AURORA RD STE 3
Practice Address - Street 2:
Practice Address - City:SAGAMORE HILLS
Practice Address - State:OH
Practice Address - Zip Code:44067-1600
Practice Address - Country:US
Practice Address - Phone:216-524-4009
Practice Address - Fax:216-524-7933
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHCOAST DERMATOLOGY ASSOCIATES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0289727Medicaid
OHCD6030OtherRAILROAD MEDICARE
OH0289727Medicaid