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General NPI Number Information
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NPI Number | 1548500465
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Entity Type | Organization
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Legal Business Name | DERMATOLOGY ASSOCIATES OF NORTHWEST INDIANA, PC
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Dates
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Enumeration Date | 03/01/2013
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Last Update Date | 12/17/2018
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Provider Practice Location Address
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Address Line | 311 E 89TH AVE
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City | MERRILLVILLE
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State | IN
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Zip | 46410-8126
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Country | US
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Telephone | 773-255-8873
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Fax | 773-304-1490
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Provider Business Mailing Address
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Address Line | 25 HARDWOOD HILL RD
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City | PITTSFORD
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State | NY
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Zip | 14534-4545
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Country | US
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Telephone | 219-302-0322
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Fax |
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | ANNE JORDAN
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Credential |
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Telephone | 219-302-0322
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 01057516
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License Number State | IN
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