Provider Demographics
NPI:1952549792
Name:IC DERMATOLOGY PC
Entity Type:Organization
Organization Name:IC DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLERAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-338-3972
Mailing Address - Street 1:269 N 1ST AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52245-3616
Mailing Address - Country:US
Mailing Address - Phone:319-339-3972
Mailing Address - Fax:319-339-3974
Practice Address - Street 1:269 N 1ST AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52245-3616
Practice Address - Country:US
Practice Address - Phone:319-339-3972
Practice Address - Fax:319-339-3974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-02
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA28400207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIB2694Medicare UPIN