=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700169125
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROSE DERMATOLOGY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2011
-----------------------------------------------------
Last Update Date | 10/28/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3074 31ST ST 1A
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11102-1857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-728-3376
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3074 31ST ST 1A
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11102-1857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-728-3376
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. LILLY-ROSE PARASKEVAS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 917-673-4159
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 243252
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------