=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942401070
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR DERMATOLOGIC CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2007
-----------------------------------------------------
Last Update Date | 02/02/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 170 AVENUE AT THE COMMON SUITE 2
-----------------------------------------------------
City | SHREWSBURY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07702-4803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-542-6300
-----------------------------------------------------
Fax | 732-542-6392
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 170 AVENUE AT THE COMMON SUITE 2
-----------------------------------------------------
City | SHREWSBURY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07702-4803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-542-6300
-----------------------------------------------------
Fax | 732-542-6392
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | FORREST P RESNIKOFF
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 732-542-6300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | MA050827
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------