Provider Demographics
NPI:1124109913
Name:ADVANCED DERMATOLOGY, P.C.
Entity type:Organization
Organization Name:ADVANCED DERMATOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:LI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-256-8899
Mailing Address - Street 1:570 EGG HARBOR RD
Mailing Address - Street 2:SUITE C-1
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-2359
Mailing Address - Country:US
Mailing Address - Phone:856-256-8899
Mailing Address - Fax:856-256-8868
Practice Address - Street 1:570 EGG HARBOR RD STE C1
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2359
Practice Address - Country:US
Practice Address - Phone:856-256-8899
Practice Address - Fax:856-256-8868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2019-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07893300207ND0900X, 207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1124109913OtherNPI
31D1078763OtherCLIA
H59006Medicare UPIN