=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427224385
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNTY OF MONTGOMERY DERMATOLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2008
-----------------------------------------------------
Last Update Date | 05/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 BLACK ROCK RD
-----------------------------------------------------
City | ROYERSFORD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19468-3147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-792-2224
-----------------------------------------------------
Fax | 610-792-4026
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1600 BLACK ROCK RD
-----------------------------------------------------
City | ROYERSFORD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19468-3147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-792-2224
-----------------------------------------------------
Fax | 610-792-4026
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | MARY LOU MORRISON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 610-792-2224
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207NI0002X
-----------------------------------------------------
Taxonomy Name | Clinical & Laboratory Dermatological Immunology Physician
-----------------------------------------------------
License Number | MD018026E
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------