Healthcare Provider Details

I. General information

NPI: 1225175441
Provider Name (Legal Business Name): CAMELBACK DERMATOLOGY & SKIN SURGERY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 11/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4512 N 40TH ST
PHOENIX AZ
85018-3600
US

IV. Provider business mailing address

4512 N 40TH ST
PHOENIX AZ
85018-3600
US

V. Phone/Fax

Practice location:
  • Phone: 602-954-7546
  • Fax: 602-952-2941
Mailing address:
  • Phone: 602-954-7546
  • Fax: 602-952-2941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number31198
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number31198
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number31198
License Number StateAZ

VIII. Authorized Official

Name: JEFFREY LEE ROMINE
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 602-954-7546