Provider Demographics
NPI:1053421610
Name:DERMATOLOGY INC
Entity type:Organization
Organization Name:DERMATOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KHRISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:AUTAJAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-926-3739
Mailing Address - Street 1:875 AIRPORT PKWY
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1085
Mailing Address - Country:US
Mailing Address - Phone:317-926-3739
Mailing Address - Fax:317-921-7478
Practice Address - Street 1:875 AIRPORT PKWY
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1085
Practice Address - Country:US
Practice Address - Phone:317-926-3739
Practice Address - Fax:317-921-7478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2022-09-22
Deactivation Date:2022-08-19
Deactivation Code:
Reactivation Date:2022-09-22
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100056130 AMedicaid
IN061500Medicare PIN
IN184780Medicare PIN
IN184770Medicare PIN