Provider Demographics
NPI:1285614834
Name:ADULT & PEDIATRIC DERMATOLOGY, P.C.
Entity type:Organization
Organization Name:ADULT & PEDIATRIC DERMATOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:GOOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-371-7010
Mailing Address - Street 1:526 MAIN ST STE 302
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-3301
Mailing Address - Country:US
Mailing Address - Phone:978-371-7010
Mailing Address - Fax:978-371-0522
Practice Address - Street 1:54 BAKER AVENUE EXT STE 305&306
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-2137
Practice Address - Country:US
Practice Address - Phone:978-371-7010
Practice Address - Fax:978-371-0522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM17456OtherBC/BS OF MA GROUP NUMBER
MA607334OtherTUFTS HEALTH PLAN GROUP #
MAM15841Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER