Healthcare Provider Details

I. General information

NPI: 1194757518
Provider Name (Legal Business Name): SWAN DERMATOLOGY CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 05/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 UNION ST., SUITE 300
LAFAYETTE IN
47904
US

IV. Provider business mailing address

2020 UNION ST., SUITE 300
LAFAYETTE IN
47904
US

V. Phone/Fax

Practice location:
  • Phone: 765-446-0282
  • Fax: 765-446-8299
Mailing address:
  • Phone: 765-446-0282
  • Fax: 765-446-8299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number01042461
License Number StateIN

VIII. Authorized Official

Name: LORI SIEGERT SWAN
Title or Position: PRESIDENT
Credential: MD
Phone: 765-446-0282