MEDICARE: NEW HORIZON DERMATOLOGY, INC

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	174400000X	Specialist	35-07-30985	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	292581828002	OTHER	ND	MEDICAL MUTUAL
2	000000352318	OTHER	ND	ANTHEM

General Provider Information

NPI Number	:	1285780031
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW HORIZON DERMATOLOGY, INC

Provider Business Mailing Address
First Line	:	6693 N CHESTNUT ST STE 125A
Second Line	:
City	:	RAVENNA
State	:	OH
Zip	:	44266-3900
Country	:	US
Telephone Number	:	330-296-2879
Fax Number	:	330-296-4656

Provider Business Practice Location Address
First Line	:	6693 N CHESTNUT ST STE 125A
Second Line	:
City	:	RAVENNA
State	:	OH
Zip	:	44266-3900
Country	:	US
Telephone Number	:	330-296-2879
Fax Number	:	330-296-4656

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MICHELLE A JAHNKE
Credential	:	M.D.
Telephone Number	:	330-296-2879

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	05/02/2008

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