Healthcare Provider Details

I. General information

NPI: 1386399749
Provider Name (Legal Business Name): SKIN DERMATOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2022
Last Update Date: 02/15/2022
Certification Date: 02/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 45TH ST STE 200
MUNSTER IN
46321-3958
US

IV. Provider business mailing address

1950 45TH ST STE 200
MUNSTER IN
46321-3958
US

V. Phone/Fax

Practice location:
  • Phone: 219-912-3376
  • Fax: 219-529-6267
Mailing address:
  • Phone: 219-912-3376
  • Fax: 219-529-6267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: NAMRATA SHAH
Title or Position: PARTNER
Credential: MD
Phone: 312-961-4067