MEDICARE: DERMATOLOGY CENTER OF STAMFORD, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CF8653	OTHER	CT	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1356343883
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERMATOLOGY CENTER OF STAMFORD, LLC

Provider Business Mailing Address
First Line	:	1290 SUMMER ST
Second Line	:	SUITE 3600
City	:	STAMFORD
State	:	CT
Zip	:	06905-5360
Country	:	US
Telephone Number	:	203-325-3576
Fax Number	:	203-325-4280

Provider Business Practice Location Address
First Line	:	1290 SUMMER ST
Second Line	:	SUITE 3600
City	:	STAMFORD
State	:	CT
Zip	:	06905-5360
Country	:	US
Telephone Number	:	203-325-3576
Fax Number	:	203-325-4280

Authorized Official
Title or Position	:	PHYSICIAN/PRESIDENT
Name	:	DEBRA PRUZAN-CLAIN
Credential	:	M.D.
Telephone Number	:	203-325-3576

Provider Enumeration Date	:	08/15/2005
Last Update Date	:	03/13/2015

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