MEDICARE: PROCEDURAL DERMATOLOGY PC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207ND0101X	MOHS-Micrographic Surgery Physician
2	207NS0135X	Procedural Dermatology Physician
3	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1164299004
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROCEDURAL DERMATOLOGY PC

Provider Business Mailing Address
First Line	:	262 CENTRAL PARK W STE 1D
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10024-3512
Country	:	US
Telephone Number	:	718-255-7546
Fax Number	:	917-975-6272

Provider Business Practice Location Address
First Line	:	4925 BROADWAY
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10034-3101
Country	:	US
Telephone Number	:	718-255-7546
Fax Number	:	917-975-6272

Authorized Official
Title or Position	:	PRESIDENT
Name	:	IRENE VERGILIS-KALNER
Credential	:	MD
Telephone Number	:	917-804-4553

Provider Enumeration Date	:	12/11/2023
Last Update Date	:	02/28/2024

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