Basic Information
| Provider Information | |||||||||
| NPI: | 1932196060 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED DERMATOLOGY ASSOCIATES, LTD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1259 S CEDAR CREST BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181036206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104374134 | ||||||||
| FaxNumber: | 6107700993 | ||||||||
| Practice Location | |||||||||
| Address1: | 1259 S CEDAR CREST BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181036206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104374134 | ||||||||
| FaxNumber: | 6104339690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 01/17/2022 | ||||||||
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| AuthorizedOfficialLastName: | PURCELL | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6104374134 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 01/17/2022 | ||||||||
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 |
ID Information
| ID | Type | State | Issuer | Description | CA0756 | 01 | PA | RAILROAD MEDICARE | OTHER | 02343000 | 01 | PA | CAPITAL BLUE CROSS GROUP# | OTHER | 172424 | 01 | PA | HIGHMARK GROUP NUMBER | OTHER | 1007735450013 | 05 | PA | MEDICAID |