Provider Demographics
NPI:1952172686
Name:SUMMIT DERMATOLOGY AND AESTHETICS
Entity type:Organization
Organization Name:SUMMIT DERMATOLOGY AND AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-858-3642
Mailing Address - Street 1:1910 E BARNETT RD STE 101
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8672
Mailing Address - Country:US
Mailing Address - Phone:541-200-2022
Mailing Address - Fax:
Practice Address - Street 1:1910 E BARNETT RD STE 101
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8672
Practice Address - Country:US
Practice Address - Phone:541-200-2022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-11
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty