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NPI Code Detail

MEDICARE: THREE RIVERS DERMATOLOGY, LLC

MEDICARE: THREE RIVERS 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
1174400000XSpecialist

General Provider Information

NPI Number : 1992991475
Entity Type Code : Organization
Provider Name (Legal Business Name) : THREE RIVERS DERMATOLOGY, LLC
Provider Business Mailing Address
First Line : 5650 COVENTRY LN
Second Line :
City : FORT WAYNE
State : IN
Zip : 46804-7140
Country : US
Telephone Number : 260-436-9696
Fax Number : 260-436-9424
Provider Business Practice Location Address
First Line : 5650 COVENTRY LN
Second Line :
City : FORT WAYNE
State : IN
Zip : 46804-7140
Country : US
Telephone Number : 260-436-9696
Fax Number : 260-436-9424
Authorized Official
Title or Position : CEO/OWNER
Name : DR. JEFFREY WALTER SASSMANNSHAUSEN
Credential : M.D.
Telephone Number : 260-436-9696
Provider Enumeration Date : 09/19/2007
Last Update Date : 06/12/2020

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Directions to “THREE RIVERS DERMATOLOGY, LLC ” Practice Location

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