Provider Demographics
NPI:1952413080
Name:CHARLES COUNTY DERMATOLOGY ASSOCIATES LLC
Entity Type:Organization
Organization Name:CHARLES COUNTY DERMATOLOGY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:301-843-1600
Mailing Address - Street 1:P.O BOX 791011
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279
Mailing Address - Country:US
Mailing Address - Phone:301-843-1600
Mailing Address - Fax:301-645-4734
Practice Address - Street 1:4225 ALTAMONT PLACE
Practice Address - Street 2:UNIT 3
Practice Address - City:WHITE PLAINS
Practice Address - State:MD
Practice Address - Zip Code:20695
Practice Address - Country:US
Practice Address - Phone:301-843-1600
Practice Address - Fax:301-645-4734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD415POtherMEDICARE GROUP