Provider Demographics
NPI:1548500465
Name:DERMATOLOGY ASSOCIATES OF NORTHWEST INDIANA, PC
Entity type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF NORTHWEST INDIANA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-302-0322
Mailing Address - Street 1:25 HARDWOOD HILL RD
Mailing Address - Street 2:
Mailing Address - City:PITTSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14534-4545
Mailing Address - Country:US
Mailing Address - Phone:219-302-0322
Mailing Address - Fax:
Practice Address - Street 1:311 E 89TH AVE
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-8126
Practice Address - Country:US
Practice Address - Phone:773-255-8873
Practice Address - Fax:773-304-1490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-01
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057516207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200465340Medicaid
IN200465340Medicaid