Provider Demographics
NPI:1215259452
Name:SKIN MD PA
Entity type:Organization
Organization Name:SKIN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:SWAYDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-595-4500
Mailing Address - Street 1:8820 MARTIN DR
Mailing Address - Street 2:
Mailing Address - City:NORTH RICHLAND HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76182-4801
Mailing Address - Country:US
Mailing Address - Phone:817-595-4500
Mailing Address - Fax:817-595-4505
Practice Address - Street 1:8820 MARTIN DR
Practice Address - Street 2:
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76182-4801
Practice Address - Country:US
Practice Address - Phone:817-595-4500
Practice Address - Fax:817-595-4505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-15
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8526207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty