=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992123525
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DERMATOLOGY PROFESSIONALS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2014
-----------------------------------------------------
Last Update Date | 10/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 153 E WASHINGTON ST
-----------------------------------------------------
City | NORTH ATTLEBORO
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02760-2312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-699-7546
-----------------------------------------------------
Fax | 508-699-7570
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 526 MAIN ST STE 302
-----------------------------------------------------
City | ACTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01720-3301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-371-7010
-----------------------------------------------------
Fax | 978-371-0522
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGING PARTNER
-----------------------------------------------------
Name | DR. SAMUEL D GOOS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 978-371-7010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------