Provider Demographics
NPI:1316095722
Name:PARK CITY DERMATOLOGY. CO
Entity type:Organization
Organization Name:PARK CITY DERMATOLOGY. CO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:KERN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-658-1013
Mailing Address - Street 1:1790 SUN PEAK DR STE A103
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-6625
Mailing Address - Country:US
Mailing Address - Phone:435-658-1013
Mailing Address - Fax:435-658-3513
Practice Address - Street 1:1790 SUN PEAK DR STE A103
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098
Practice Address - Country:US
Practice Address - Phone:435-658-1013
Practice Address - Fax:435-658-3513
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARK CITY DERMATOLOGY. CO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3673151205207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTBK2420987OtherDEA