Healthcare Provider Details

I. General information

NPI: 1902963358
Provider Name (Legal Business Name): BOARD CERTIFIED DERMATOPATHOLOGY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 03/10/2023
Certification Date: 03/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5208 MAHONING AVE SUITE 208
YOUNGSTOWN OH
44515-1858
US

IV. Provider business mailing address

5208 MAHONING AVE SUITE 208
YOUNGSTOWN OH
44515-1858
US

V. Phone/Fax

Practice location:
  • Phone: 330-799-9270
  • Fax: 330-799-2295
Mailing address:
  • Phone: 330-799-9270
  • Fax: 330-799-2295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberME84498
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberMD418830
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number0101231016
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number20881
License Number StateWV
# 5
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number35074029
License Number StateOH

VIII. Authorized Official

Name: DR. PAMELA MARIE GUERRIERE-KOVACH
Title or Position: DOCTOR
Credential: M.D.
Phone: 330-270-1832