Provider Demographics
NPI:1861491243
Name:PHILADELPHIA DERMATOLOGY ASSOCIATES, PC
Entity type:Organization
Organization Name:PHILADELPHIA DERMATOLOGY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:R
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-928-1493
Mailing Address - Street 1:220 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5505
Mailing Address - Country:US
Mailing Address - Phone:215-928-1493
Mailing Address - Fax:215-928-1786
Practice Address - Street 1:220 S 8TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5505
Practice Address - Country:US
Practice Address - Phone:215-928-1493
Practice Address - Fax:215-928-1786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD028614L207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C27160Medicare UPIN
54727Medicare ID - Type Unspecified