Provider Demographics
NPI:1144362179
Name:PLYMOUTH DERMATOLOGY ASSOCIATES, PC
Entity type:Organization
Organization Name:PLYMOUTH DERMATOLOGY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:N
Authorized Official - Last Name:FARBER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-746-5300
Mailing Address - Street 1:345 COURT ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-4329
Mailing Address - Country:US
Mailing Address - Phone:508-746-5300
Mailing Address - Fax:508-747-2001
Practice Address - Street 1:345 COURT ST
Practice Address - Street 2:SUITE 201
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-4329
Practice Address - Country:US
Practice Address - Phone:508-746-5300
Practice Address - Fax:508-747-2001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM16586OtherBLUE CROSS AND BLUE SHIELD
MACN6573OtherRAILROAD MEDICARE
MAM20298Medicare PIN