Healthcare Provider Details

I. General information

NPI: 1821264193
Provider Name (Legal Business Name): ADVANCED DERMATOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2008
Last Update Date: 05/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 COMMACK RD
COMMACK NY
11725-3412
US

IV. Provider business mailing address

6 LOWELL AVE
NEW HYDE PARK NY
11040-2810
US

V. Phone/Fax

Practice location:
  • Phone: 631-499-1200
  • Fax: 631-499-4301
Mailing address:
  • Phone: 516-326-4160
  • Fax: 516-437-0482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. LEWIS LIPPNER
Title or Position: ADMINISTRATOR
Credential:
Phone: 516-326-4160