Healthcare Provider Details

I. General information

NPI: 1033715032
Provider Name (Legal Business Name): ASSOCIATES IN DERMATOLOGY AND COSMETIC SURGERY-THE MILLBURN LASER CENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2020
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73 SPRING ST RM 303
NEW YORK NY
10012-5801
US

IV. Provider business mailing address

73 SPRING ST RM 303
NEW YORK NY
10012-5801
US

V. Phone/Fax

Practice location:
  • Phone: 646-906-9614
  • Fax:
Mailing address:
  • Phone: 646-906-9614
  • Fax:

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

VIII. Authorized Official

Name: ERIC SCOTT SIEGEL
Title or Position: OWNER
Credential:
Phone: 973-376-8500