Provider Demographics
NPI:1215331228
Name:CENTURION DERMATOLOGY PC
Entity type:Organization
Organization Name:CENTURION DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENTLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-491-8918
Mailing Address - Street 1:6811 FORT HAMILTON PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-5856
Mailing Address - Country:US
Mailing Address - Phone:718-491-8918
Mailing Address - Fax:718-491-8915
Practice Address - Street 1:6811 FORT HAMILTON PARKWAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219
Practice Address - Country:US
Practice Address - Phone:718-491-8918
Practice Address - Fax:718-491-8915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-20
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY157066207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400001624Medicare UPIN