Healthcare Provider Details

I. General information

NPI: 1669482105
Provider Name (Legal Business Name): FAMILY DERMATOLOGY OF PENNSYLVANIA, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 09/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 HEARTHSTONE CT SUITE 101
READING PA
19606-3065
US

IV. Provider business mailing address

629 BEAVER RUIN RD NW SUITE B
LILBURN GA
30047-3468
US

V. Phone/Fax

Practice location:
  • Phone: 610-779-7773
  • Fax: 610-779-7775
Mailing address:
  • Phone: 770-921-4300
  • Fax: 770-381-6451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PAULA M. NELSON
Title or Position: OWNER
Credential: MD
Phone: 215-483-3666