Provider Demographics
NPI:1194757518
Name:SWAN DERMATOLOGY CENTER, PC
Entity type:Organization
Organization Name:SWAN DERMATOLOGY CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:SIEGERT
Authorized Official - Last Name:SWAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-446-0282
Mailing Address - Street 1:2020 UNION ST., SUITE 300
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904
Mailing Address - Country:US
Mailing Address - Phone:765-446-0282
Mailing Address - Fax:765-446-8299
Practice Address - Street 1:2020 UNION ST., SUITE 300
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904
Practice Address - Country:US
Practice Address - Phone:765-446-0282
Practice Address - Fax:765-446-8299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042461207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INCE9089OtherRR MEDICARE
IN131930AMedicare ID - Type Unspecified
F79624Medicare UPIN