=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306968797
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DERMATOLOGY CENTER PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2007
-----------------------------------------------------
Last Update Date | 03/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 685 MISSION HILL WAY
-----------------------------------------------------
City | COLORADO SPGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80921-2671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-488-8724
-----------------------------------------------------
Fax | 719-531-9545
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 685 MISSION HILL WAY
-----------------------------------------------------
City | COLORADO SPGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80921-2671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-488-8724
-----------------------------------------------------
Fax | 719-531-9545
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CHARLES G HUGHES
-----------------------------------------------------
Credential | D. O.
-----------------------------------------------------
Telephone | 719-488-8724
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ND0900X
-----------------------------------------------------
Taxonomy Name | Dermatopathology Physician
-----------------------------------------------------
License Number | 22263
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207NS0135X
-----------------------------------------------------
Taxonomy Name | Procedural Dermatology Physician
-----------------------------------------------------
License Number | 22263
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 22263
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------