Basic Information
| Provider Information | |||||||||
| NPI: | 1174736516 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREATER WASHINGTON DERMATOLOGY PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 RESEARCH BLVD STE 260 | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208503261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019906565 | ||||||||
| FaxNumber: | 3019908525 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 RESEARCH BLVD STE 260 | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208503261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019906565 | ||||||||
| FaxNumber: | 3019908525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2007 | ||||||||
| LastUpdateDate: | 12/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | BARNETT | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3019906565 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | D0043966 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 171451100 | 05 | MD | MEDICAID |