Provider Demographics
NPI:1962795302
Name:DERMATOLOGY & AESTHETIC CARE LLC
Entity type:Organization
Organization Name:DERMATOLOGY & AESTHETIC CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-436-1117
Mailing Address - Street 1:1299 E ALEX BELL RD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-2658
Mailing Address - Country:US
Mailing Address - Phone:937-436-1117
Mailing Address - Fax:937-436-9576
Practice Address - Street 1:1299 E ALEX BELL RD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-2658
Practice Address - Country:US
Practice Address - Phone:937-436-1117
Practice Address - Fax:937-436-9576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-18
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0055983Medicaid
OH0055983Medicaid