Healthcare Provider Details

I. General information

NPI: 1639289093
Provider Name (Legal Business Name): NORTHERN INDIANA DERMATOLOGY AND SKIN SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3190 LANCER ST
PORTAGE IN
46368-4488
US

IV. Provider business mailing address

3190 LANCER ST
PORTAGE IN
46368-4488
US

V. Phone/Fax

Practice location:
  • Phone: 219-764-3600
  • Fax: 219-764-3661
Mailing address:
  • Phone: 219-764-3600
  • Fax: 219-764-3661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number207N00000X
License Number StateIN

VIII. Authorized Official

Name: DR. RUCHIK S DESAI
Title or Position: PHYSICIAN
Credential:
Phone: 219-764-3600