Provider Demographics
NPI:1053771048
Name:DERMONE DERMATOLOGY ASSOCIATES OF THE GARDEN STATE, PC
Entity type:Organization
Organization Name:DERMONE DERMATOLOGY ASSOCIATES OF THE GARDEN STATE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL & ADMIN. OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:484-240-6550
Mailing Address - Street 1:FOUR TOWER BRIDGE, 200 BARR HARBOR DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WEST CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-1518
Mailing Address - Country:US
Mailing Address - Phone:848-240-2812
Mailing Address - Fax:732-731-6135
Practice Address - Street 1:501 IRON BRIDGE ROAD
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728
Practice Address - Country:US
Practice Address - Phone:800-337-6663
Practice Address - Fax:732-731-6135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-03
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty