Healthcare Provider Details

I. General information

NPI: 1962802249
Provider Name (Legal Business Name): CARLISLE DERMATOLOGY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2014
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 SPRINT DRIVE SUITE 1
CARLISLE PA
17015-7002
US

IV. Provider business mailing address

19 SPRINT DRIVE SUITE 1
CARLISLE PA
17015-7002
US

V. Phone/Fax

Practice location:
  • Phone: 717-701-8251
  • Fax: 717-701-8289
Mailing address:
  • Phone: 717-701-8251
  • Fax: 717-701-8289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberOS17070
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JULIAN MAP NGO
Title or Position: OWNER/PRESIDENT
Credential: D.O.
Phone: 717-701-8251