Provider Demographics
NPI:1053417055
Name:DERMATOLOGY CENTER FOR CHILDREN & YOUNG ADULTS PA
Entity type:Organization
Organization Name:DERMATOLOGY CENTER FOR CHILDREN & YOUNG ADULTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:E
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:651-379-9999
Mailing Address - Street 1:2795 PILOT KNOB RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-1176
Mailing Address - Country:US
Mailing Address - Phone:651-379-9999
Mailing Address - Fax:651-379-9900
Practice Address - Street 1:2795 PILOT KNOB RD
Practice Address - Street 2:SUITE 300
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-1176
Practice Address - Country:US
Practice Address - Phone:651-379-9999
Practice Address - Fax:651-379-9900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2M741DEOtherBLUE CROSS BLUE SHIELD
ND013837Medicaid
2M741DEOtherBLUE CROSS BLUE SHIELD
=========OtherCOMMERCIAL - FED TAX ID