Healthcare Provider Details

I. General information

NPI: 1538204870
Provider Name (Legal Business Name): DERMATOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N WABASH AVE #360
MARION IN
47342-9999
US

IV. Provider business mailing address

330 N WABASH AVE #360
MARION IN
46952-2600
US

V. Phone/Fax

Practice location:
  • Phone: 765-664-3292
  • Fax: 765-662-7560
Mailing address:
  • Phone: 765-664-3292
  • Fax: 765-662-7560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number50003832A
License Number StateIN

VIII. Authorized Official

Name: DR. KRISTINE A. HESS
Title or Position: PRESIDENT
Credential: MD
Phone: 765-664-3292