Provider Demographics
NPI:1962402776
Name:TRI COUNTY DERMATOLOGY INC
Entity type:Organization
Organization Name:TRI COUNTY DERMATOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/GENERAL PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCHIELD
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:WIKAS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:330-929-9009
Mailing Address - Street 1:4240 MUNSON ST NW STE C
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2978
Mailing Address - Country:US
Mailing Address - Phone:330-492-2327
Mailing Address - Fax:330-492-0953
Practice Address - Street 1:421 GRAHAM RD
Practice Address - Street 2:SUITE C
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44221-1344
Practice Address - Country:US
Practice Address - Phone:330-929-9009
Practice Address - Fax:330-929-6264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-22
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003166207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9268761Medicare PIN