MEDICARE: ADVANCED DERMATOLOGY OF NEW YORK PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	108361052	OTHER		NPI

General Provider Information

NPI Number	:	1083610521
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED DERMATOLOGY OF NEW YORK PC

Provider Business Mailing Address
First Line	:	200 CENTRAL PARK S
Second Line	:	STE 107
City	:	NEW YORK
State	:	NY
Zip	:	10019-1449
Country	:	US
Telephone Number	:	212-262-2500
Fax Number	:	212-246-0890

Provider Business Practice Location Address
First Line	:	200 CENTRAL PARK S
Second Line	:	STE 107
City	:	NEW YORK
State	:	NY
Zip	:	10019-1449
Country	:	US
Telephone Number	:	212-262-2500
Fax Number	:	212-246-0890

Authorized Official
Title or Position	:	OFFICER
Name	:	MR. LAWRENCE D JAEGER
Credential	:	D.O.
Telephone Number	:	212-262-2500

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	12/10/2014

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