Provider Demographics
NPI:1386078236
Name:ADVANCED DERMATOLOGY OF NEW YORK PC
Entity type:Organization
Organization Name:ADVANCED DERMATOLOGY OF NEW YORK PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:JAEGER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:212-262-2500
Mailing Address - Street 1:200 CENTRAL PARK S
Mailing Address - Street 2:SUITE 107
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-1436
Mailing Address - Country:US
Mailing Address - Phone:212-262-2500
Mailing Address - Fax:212-765-3210
Practice Address - Street 1:200 CENTRAL PARK S
Practice Address - Street 2:SUITE 107
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1436
Practice Address - Country:US
Practice Address - Phone:212-262-2500
Practice Address - Fax:212-765-3210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW337062Medicare PIN
NYW37061Medicare PIN