Healthcare Provider Details

I. General information

NPI: 1205104601
Provider Name (Legal Business Name): DERMATOLOGIC SURGERY CENTER OF NORTHEAST OHIO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2011
Last Update Date: 02/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 MEDINA RD SUITE 100
MEDINA OH
44256-0000
US

IV. Provider business mailing address

1133 MEDINA RD SUITE 100
MEDINA OH
44256
US

V. Phone/Fax

Practice location:
  • Phone: 330-238-4350
  • Fax: 330-239-4584
Mailing address:
  • Phone: 330-239-4350
  • Fax: 330-239-4584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number35076146P
License Number StateOH

VIII. Authorized Official

Name: JENNIFER POPOVSKY
Title or Position: PRESIDENT
Credential: MD
Phone: 330-239-4350