Provider Demographics
NPI:1699982454
Name:SKIN AND ALLERGY CLINIC, INC.
Entity type:Organization
Organization Name:SKIN AND ALLERGY CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MUSHTAQ
Authorized Official - Middle Name:AHMAD
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-492-1117
Mailing Address - Street 1:6801 GRAYSTONE CIR NW
Mailing Address - Street 2:DR. KHAN - DERMATOLOGIST
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-1372
Mailing Address - Country:US
Mailing Address - Phone:330-546-0135
Mailing Address - Fax:925-380-8129
Practice Address - Street 1:6801 GRAYSTONE CIR NW
Practice Address - Street 2:DR. KHAN - DERMATOLOGIST
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-1372
Practice Address - Country:US
Practice Address - Phone:330-546-0135
Practice Address - Fax:925-380-8129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35037786207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0350310Medicaid
OHKH0416036Medicare PIN
OH9167384Medicare PIN
OH0350310Medicaid