Provider Demographics
NPI:1285079038
Name:ORLEANS DERMATOLOGY & LASER THERAPIES, LLC
Entity type:Organization
Organization Name:ORLEANS DERMATOLOGY & LASER THERAPIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICIAL / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAVITZ
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-BC
Authorized Official - Phone:508-255-4050
Mailing Address - Street 1:3 NAMSKAKET ROAD
Mailing Address - Street 2:
Mailing Address - City:ORLEANS
Mailing Address - State:MA
Mailing Address - Zip Code:02653
Mailing Address - Country:US
Mailing Address - Phone:508-255-4050
Mailing Address - Fax:888-448-6765
Practice Address - Street 1:3 NAMSKAKET ROAD
Practice Address - Street 2:
Practice Address - City:ORLEANS
Practice Address - State:MA
Practice Address - Zip Code:02653
Practice Address - Country:US
Practice Address - Phone:508-255-4050
Practice Address - Fax:888-448-6765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-07
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM2500X
MARN/NP195664363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1706503OtherCIGNA