Provider Demographics
NPI:1194479725
Name:INTEGRATED DERMATOLOGY OF NORTHSHORE LLC
Entity type:Organization
Organization Name:INTEGRATED DERMATOLOGY OF NORTHSHORE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:TABOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-641-5198
Mailing Address - Street 1:393 HIGHWAY 21 STE 550
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70447-3447
Mailing Address - Country:US
Mailing Address - Phone:985-641-5198
Mailing Address - Fax:866-755-7181
Practice Address - Street 1:393 HIGHWAY 21 STE 550
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:LA
Practice Address - Zip Code:70447-3447
Practice Address - Country:US
Practice Address - Phone:985-641-5198
Practice Address - Fax:866-755-7181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-11
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty