Provider Demographics
NPI:1427169218
Name:CENTRE DERMATOLOGY PC
Entity type:Organization
Organization Name:CENTRE DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:KOZMINSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-237-6600
Mailing Address - Street 1:2505 GREEN TECH DR STE A1
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-2316
Mailing Address - Country:US
Mailing Address - Phone:814-237-6600
Mailing Address - Fax:
Practice Address - Street 1:2505 GREEN TECH DR STE A1
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-2316
Practice Address - Country:US
Practice Address - Phone:814-237-6600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-033463-E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
B37143Medicare UPIN
064807Medicare ID - Type Unspecified