Healthcare Provider Details

I. General information

NPI: 1598176554
Provider Name (Legal Business Name): PHILADELPHIA CENTER FOR DERMATOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 08/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8400 ROOSEVELT BLVD SUITE 200
PHILADELPHIA PA
19152-2081
US

IV. Provider business mailing address

8400 ROOSEVELT BLVD SUITE 200
PHILADELPHIA PA
19152-2081
US

V. Phone/Fax

Practice location:
  • Phone: 267-538-5045
  • Fax: 267-538-2153
Mailing address:
  • Phone: 267-538-5045
  • Fax: 267-538-2153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberMD440883
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberMD440883
License Number StatePA

VIII. Authorized Official

Name: ATSUKO KODAMA
Title or Position: OWNER
Credential: M.D.
Phone: 267-538-5045