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General NPI Number Information
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NPI Number | 1356376917
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Entity Type | Organization
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Legal Business Name | FAIRLAWN DERMATOLOGY, LLC
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Dates
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Enumeration Date | 07/12/2006
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Last Update Date | 02/18/2013
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Provider Practice Location Address
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Address Line | 55 MERZ BLVD SUITE A
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City | FAIRLAWN
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State | OH
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Zip | 44333-2895
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Country | US
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Telephone | 330-864-9000
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Fax | 330-864-9004
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Provider Business Mailing Address
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Address Line | 55 MERZ BLVD SUITE A
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City | FAIRLAWN
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State | OH
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Zip | 44333-2895
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Country | US
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Telephone | 330-864-9000
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Fax | 330-864-9004
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Authorized Official
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Title or Position | PHYSICIAN
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Name | VALERIE W FULLER
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Credential | D.O.
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Telephone | 330-864-9000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 8780
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License Number State | OH
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