Provider Demographics
NPI:1447272398
Name:MEDICAL AND COSMETIC DERMATOLOGY OF CAPE COD
Entity type:Organization
Organization Name:MEDICAL AND COSMETIC DERMATOLOGY OF CAPE COD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:ISRAEL
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:508-771-7790
Mailing Address - Street 1:PO BOX 845963
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284
Mailing Address - Country:US
Mailing Address - Phone:508-771-7790
Mailing Address - Fax:508-771-7793
Practice Address - Street 1:700 ATTUCKS LN
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-1809
Practice Address - Country:US
Practice Address - Phone:508-771-7790
Practice Address - Fax:508-771-7793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM18885OtherBLUE SHIELD
MA9735810Medicaid
MAM18885OtherBLUE SHIELD