Basic Information
Provider Information | |||||||||
NPI: | 1265008940 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FOREFRONT DERMATOLOGY - EAST, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 801 YORK ST | ||||||||
Address2: |   | ||||||||
City: | MANITOWOC | ||||||||
State: | WI | ||||||||
PostalCode: | 542204630 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9206639008 | ||||||||
FaxNumber: | 9206841439 | ||||||||
Practice Location | |||||||||
Address1: | 222 COLUMBIA TPKE | ||||||||
Address2: |   | ||||||||
City: | FLORHAM PARK | ||||||||
State: | NJ | ||||||||
PostalCode: | 079321299 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9735418138 | ||||||||
FaxNumber: | 9738001949 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2021 | ||||||||
LastUpdateDate: | 06/02/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WERNLI | ||||||||
AuthorizedOfficialFirstName: | BETSY | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9204820671 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 06/02/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0101X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207NS0135X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 207N00000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |   |
No ID Information.