MEDICARE: WHEATLAND DERMATOLOGY 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	207N00000X	Dermatology Physician	35120090	OH

General Provider Information

NPI Number	:	1477931608
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHEATLAND DERMATOLOGY LLC

Provider Business Mailing Address
First Line	:	1050 EAST GREENVILLE RD
Second Line	:
City	:	ST MARYS
State	:	OH
Zip	:	45885-2622
Country	:	US
Telephone Number	:	419-394-3331
Fax Number	:	419-394-3330

Provider Business Practice Location Address
First Line	:	1050 EAST GREENVILLE RD
Second Line	:
City	:	ST MARYS
State	:	OH
Zip	:	45885-4588
Country	:	US
Telephone Number	:	419-394-3331
Fax Number	:	419-394-3330

Authorized Official
Title or Position	:	OWNER
Name	:	SUZANNE QUINTER
Credential	:	MD
Telephone Number	:	419-290-8672

Provider Enumeration Date	:	05/07/2015
Last Update Date	:	01/09/2023

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Directions to “WHEATLAND DERMATOLOGY LLC ” Practice Location

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