NPIMap

Organization Active NPI

Dermatology Center of Northwest Indiana, PC

  • Dermatology Physician
  • Crown Point, IN
National Provider Identifier
1134585029
Registry record updated Jan 7, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
License
01031629A Issued in IN
Legal business name
DERMATOLOGY CENTER OF NORTHWEST INDIANA, PC
Practice address
70 W 94TH PL
Crown Point, IN 46307-1710
Phone
(219) 662-8822
Fax
(219) 662-8833
NPI assigned
Jan 7, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 7, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Mitchell Leslie Bressack, M.D.
Title
Owner
Phone
(219) 662-8856

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207N00000X 01031629A IN Primary
Dermatology PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207N00000X 02004576A IN
Dermatopathology PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207ND0900X 01043884A IN
Medical Physician AssistantGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 363AM0700X 10000889A IN

Addresses

Primary practice location

70 W 94TH PL
Crown Point, IN 46307-1710

Mailing address

70 W 94TH PL
Crown Point, IN 46307-1710
Phone (219) 662-8822

Other identifiers 3

IdentifierTypeStateIssuer
201294150MedicaidIN
100214910AMedicaidIN
200039710AMedicaidIN

National Provider Directory

National Provider Directory

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1452124800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1452124800000",
    "number": "1134585029",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "70 W 94TH PL",
            "city": "CROWN POINT",
            "state": "IN",
            "postal_code": "463071710",
            "telephone_number": "219-662-8822",
            "fax_number": "219-662-8833"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "70 W 94TH PL",
            "city": "CROWN POINT",
            "state": "IN",
            "postal_code": "463071710",
            "telephone_number": "219-662-8822",
            "fax_number": "219-662-8833"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DERMATOLOGY CENTER OF NORTHWEST INDIANA, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-01-07",
        "last_updated": "2016-01-07",
        "status": "A",
        "authorized_official_last_name": "BRESSACK",
        "authorized_official_first_name": "MITCHELL",
        "authorized_official_middle_name": "LESLIE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "219-662-8856",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dermatology",
            "state": "IN",
            "license": "01031629A",
            "primary": true
        },
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dermatology",
            "state": "IN",
            "license": "02004576A",
            "primary": false
        },
        {
            "code": "207ND0900X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dermatology, Dermatopathology",
            "state": "IN",
            "license": "01043884A",
            "primary": false
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Physician Assistant, Medical",
            "state": "IN",
            "license": "10000889A",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "201294150",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100214910A",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200039710A",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Crown Point, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 7, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.