Provider Demographics
NPI:1871791954
Name:SKIN AND LASER SURGERY CENTER OF PEN
Entity type:Organization
Organization Name:SKIN AND LASER SURGERY CENTER OF PEN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:HAROLD
Authorized Official - Last Name:NEUSTADTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-735-4994
Mailing Address - Street 1:1528 WALNUT ST
Mailing Address - Street 2:STUITE 1101
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-3604
Mailing Address - Country:US
Mailing Address - Phone:215-735-4994
Mailing Address - Fax:215-735-8376
Practice Address - Street 1:1528 WALNUT ST
Practice Address - Street 2:STUITE 1101
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-3604
Practice Address - Country:US
Practice Address - Phone:215-735-4994
Practice Address - Fax:215-735-8376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD041412E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA113285501Medicaid
PA170232OtherHIGHMARK BLUE SHIELD
PA170232Medicare PIN
PAC32680Medicare UPIN