MEDICARE: COSMETIC AND PROCEDURAL DERMATOLOGY CENTER, LLC

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	207ND0101X	MOHS-Micrographic Surgery Physician	25MA07887600	NJ

General Provider Information

NPI Number	:	1295892339
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COSMETIC AND PROCEDURAL DERMATOLOGY CENTER, LLC

Provider Business Mailing Address
First Line	:	215 MORRIS AVE
Second Line	:
City	:	SPRING LAKE
State	:	NJ
Zip	:	07762-1360
Country	:	US
Telephone Number	:	732-449-3005
Fax Number	:	732-449-5110

Provider Business Practice Location Address
First Line	:	215 MORRIS AVE
Second Line	:
City	:	SPRING LAKE
State	:	NJ
Zip	:	07762-1360
Country	:	US
Telephone Number	:	732-449-3005
Fax Number	:	732-449-5110

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	J. BARTON STERLING
Credential	:	M.D.
Telephone Number	:	732-449-3005

Provider Enumeration Date	:	01/01/2007
Last Update Date	:	03/18/2013

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