Provider Demographics
NPI:1871546325
Name:DERMATOLOGY AND SKIN SURGERY CENTER, PC
Entity type:Organization
Organization Name:DERMATOLOGY AND SKIN SURGERY CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:L
Authorized Official - Last Name:GOTTLIEB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-594-6660
Mailing Address - Street 1:501 GORDON DR
Mailing Address - Street 2:
Mailing Address - City:EXTON
Mailing Address - State:PA
Mailing Address - Zip Code:19341-1252
Mailing Address - Country:US
Mailing Address - Phone:610-594-6660
Mailing Address - Fax:610-594-6810
Practice Address - Street 1:501 GORDON DR
Practice Address - Street 2:
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-1252
Practice Address - Country:US
Practice Address - Phone:610-594-6660
Practice Address - Fax:610-594-6810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2950305207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA486908OtherPENNSYLVANIA BLUE SHIELD
PA7758403OtherAETNA HEALTH PLANS
PA0100328000OtherINDEPENDENCE BLUE CROSS
PA7758403OtherAETNA HEALTH PLANS