MEDICARE: LITCHFIELD HILLS DERMATOLOGY, 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	044520	CT

General Provider Information

NPI Number	:	1629260435
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LITCHFIELD HILLS DERMATOLOGY, PC

Provider Business Mailing Address
First Line	:	409 BANTAM RD STE 2A
Second Line	:
City	:	LITCHFIELD
State	:	CT
Zip	:	06759-3200
Country	:	US
Telephone Number	:	860-361-9660
Fax Number	:	860-361-9659

Provider Business Practice Location Address
First Line	:	409 BANTAM RD STE 2A
Second Line	:
City	:	LITCHFIELD
State	:	CT
Zip	:	06759-3200
Country	:	US
Telephone Number	:	860-361-9660
Fax Number	:	860-361-9659

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BEATRICE MARIA DIAS
Credential	:	M.D.
Telephone Number	:	917-494-5777

Provider Enumeration Date	:	08/15/2007
Last Update Date	:	08/15/2007

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