Provider Demographics
NPI:1649367889
Name:SPOKANE DERMATOLOGY CLINIC PS
Entity type:Organization
Organization Name:SPOKANE DERMATOLOGY CLINIC PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DRISCOLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-624-1184
Mailing Address - Street 1:324 S SHERMAN ST
Mailing Address - Street 2:SUITE A1
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1461
Mailing Address - Country:US
Mailing Address - Phone:509-624-1184
Mailing Address - Fax:509-625-1449
Practice Address - Street 1:324 S SHERMAN ST
Practice Address - Street 2:SUITE A1
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1461
Practice Address - Country:US
Practice Address - Phone:509-624-1184
Practice Address - Fax:509-625-1449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACE1737OtherRAILROAD MEDICARE
WACE1737OtherRAILROAD MEDICARE