Healthcare Provider Details

I. General information

NPI: 1356376917
Provider Name (Legal Business Name): FAIRLAWN DERMATOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 02/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 MERZ BLVD SUITE A
FAIRLAWN OH
44333-2895
US

IV. Provider business mailing address

55 MERZ BLVD SUITE A
FAIRLAWN OH
44333-2895
US

V. Phone/Fax

Practice location:
  • Phone: 330-864-9000
  • Fax: 330-864-9004
Mailing address:
  • Phone: 330-864-9000
  • Fax: 330-864-9004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number8780
License Number StateOH

VIII. Authorized Official

Name: VALERIE W FULLER
Title or Position: PHYSICIAN
Credential: D.O.
Phone: 330-864-9000