Provider Demographics
NPI:1285808550
Name:GREENWOOD DERMATOLOGY PC
Entity type:Organization
Organization Name:GREENWOOD DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:EADS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-889-7546
Mailing Address - Street 1:53 SOUTH PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143
Mailing Address - Country:US
Mailing Address - Phone:317-889-7546
Mailing Address - Fax:317-889-2482
Practice Address - Street 1:53 SOUTH PARK BLVD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143
Practice Address - Country:US
Practice Address - Phone:317-889-7546
Practice Address - Fax:317-889-2482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01047160207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INH17291Medicare UPIN
IN185300Medicare PIN