Provider Demographics
NPI:1902963358
Name:BOARD CERTIFIED DERMATOPATHOLOGY, INC
Entity Type:Organization
Organization Name:BOARD CERTIFIED DERMATOPATHOLOGY, INC
Other - Org Name:BCD, INC
Other - Org Type:Other Name
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GUERRIERE-KOVACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-270-1832
Mailing Address - Street 1:5208 MAHONING AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-1858
Mailing Address - Country:US
Mailing Address - Phone:330-799-9270
Mailing Address - Fax:330-799-2295
Practice Address - Street 1:5208 MAHONING AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-1858
Practice Address - Country:US
Practice Address - Phone:330-799-9270
Practice Address - Fax:330-799-2295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35074029207ZD0900X
FLME84498207ZD0900X
PAMD418830207ZD0900X
VA0101231016207ZD0900X
WV20881207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000282926OtherANTHEM BCBS PROVIDER #
OH2407818Medicaid
WV6703070000Medicaid
VA010128099Medicaid
OHBOD369111Medicare ID - Type Unspecified