MEDICARE: DERMATOLOGY AND MOHS SURGERY CENTER 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	207ND0101X	MOHS-Micrographic Surgery Physician	MD074439L	PA

General Provider Information

NPI Number	:	1629279310
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERMATOLOGY AND MOHS SURGERY CENTER PC

Provider Business Mailing Address
First Line	:	1306 CONCOURSE DR STE 201
Second Line	:
City	:	LINTHICUM HEIGHTS
State	:	MD
Zip	:	21090-1033
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2003 LOWER STATE RD BLDG 200
Second Line	:
City	:	DOYLESTOWN
State	:	PA
Zip	:	18901-2622
Country	:	US
Telephone Number	:	215-345-6647
Fax Number	:	215-345-0460

Authorized Official
Title or Position	:	MD
Name	:	ANGELA RUTH PETERMAN
Credential	:
Telephone Number	:	443-351-3376

Provider Enumeration Date	:	05/30/2007
Last Update Date	:	04/23/2024

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