Provider Demographics
NPI:1992991475
Name:THREE RIVERS DERMATOLOGY, LLC
Entity type:Organization
Organization Name:THREE RIVERS DERMATOLOGY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:SASSMANNSHAUSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-436-9696
Mailing Address - Street 1:5650 COVENTRY LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7140
Mailing Address - Country:US
Mailing Address - Phone:260-436-9696
Mailing Address - Fax:260-436-9424
Practice Address - Street 1:5650 COVENTRY LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-7140
Practice Address - Country:US
Practice Address - Phone:260-436-9696
Practice Address - Fax:260-436-9424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty