Provider Demographics
NPI:1316235724
Name:AL DERMATOLOGY,PC
Entity type:Organization
Organization Name:AL DERMATOLOGY,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LYUBOV
Authorized Official - Middle Name:
Authorized Official - Last Name:AVSHALUMOVA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:212-964-4151
Mailing Address - Street 1:100 BEEKMAN ST
Mailing Address - Street 2:SUITE 22L
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-1810
Mailing Address - Country:US
Mailing Address - Phone:212-964-4151
Mailing Address - Fax:718-259-3705
Practice Address - Street 1:100 BEEKMAN ST
Practice Address - Street 2:SUITE 22L
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-1810
Practice Address - Country:US
Practice Address - Phone:212-964-4151
Practice Address - Fax:718-259-3705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY256828207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03308418Medicaid