Provider Demographics
NPI:1720611635
Name:THE DERMATOLOGY CLINIC PA
Entity type:Organization
Organization Name:THE DERMATOLOGY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PROVIDER/ PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:S
Authorized Official - Last Name:STIBICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-623-6100
Mailing Address - Street 1:3633 CENTRAL AVE STE N
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-6475
Mailing Address - Country:US
Mailing Address - Phone:501-623-6100
Mailing Address - Fax:501-623-3403
Practice Address - Street 1:1710 MALVERN AVE
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-7132
Practice Address - Country:US
Practice Address - Phone:501-623-6100
Practice Address - Fax:501-623-3403
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE DERMATOLOGY CLINIC PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-02-19
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR120956002Medicaid