Provider Demographics
NPI:1215440011
Name:CAMDEN DERMATOLOGY & MOHS SURGERY LLC
Entity type:Organization
Organization Name:CAMDEN DERMATOLOGY & MOHS SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:ALLISON
Authorized Official - Last Name:LAVIGNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD FAAD FACMS
Authorized Official - Phone:207-706-5030
Mailing Address - Street 1:195 UNION ST
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04856-6107
Mailing Address - Country:US
Mailing Address - Phone:207-706-5030
Mailing Address - Fax:877-343-6641
Practice Address - Street 1:195 UNION ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-6107
Practice Address - Country:US
Practice Address - Phone:207-706-5030
Practice Address - Fax:207-706-5030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-15
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological ImmunologyGroup - Multi-Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1215440011Medicaid