Basic Information
| Provider Information | |||||||||
| NPI: | 1760491401 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED DERMATOLOGY OF OHIO, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 SOUTHHALL LN | ||||||||
| Address2: | STE 300 | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078752080 | ||||||||
| FaxNumber: | 4076503455 | ||||||||
| Practice Location | |||||||||
| Address1: | 8940 KINGSRIDGE DR | ||||||||
| Address2: | STE 104 | ||||||||
| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454581632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374361433 | ||||||||
| FaxNumber: | 9374397443 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 02/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | DECLUE | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, PROVIDER SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 4078752080 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 2531406 | 05 | OH | MEDICAID |