MEDICARE: NY DERMATOLOGY ASSOCIATES PLLC

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

General Provider Information

NPI Number	:	1861039240
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NY DERMATOLOGY ASSOCIATES PLLC

Provider Business Mailing Address
First Line	:	277 W END AVE APT 1B
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10023-2605
Country	:	US
Telephone Number	:	212-769-0069
Fax Number	:

Provider Business Practice Location Address
First Line	:	277 W END AVE APT 1B
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10023-2605
Country	:	US
Telephone Number	:	212-769-0069
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LISA B TRAVIS
Credential	:	MD
Telephone Number	:	212-769-0069

Provider Enumeration Date	:	12/05/2019
Last Update Date	:	12/09/2019

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