=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518621663
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RADIANT DERMATOLOGY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2021
-----------------------------------------------------
Last Update Date | 02/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6990 LINDSAY DR STE 5
-----------------------------------------------------
City | MENTOR
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44060-4981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-290-9616
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6990 LINDSAY DR STE 5
-----------------------------------------------------
City | MENTOR
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44060-4981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-290-9616
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MIRIAM FINKEL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 440-290-9616
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------