NPIMap

Organization Active NPI

Worcester Dermatology Associates, P.C.

  • Specialist
  • Worcester, MA
National Provider Identifier
1144211681
Registry record updated Feb 13, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
License
75849 Issued in MA
Legal business name
WORCESTER DERMATOLOGY ASSOCIATES, P.C.
Practice address
100 Central St
Worcester, MA 01608-1209
Phone
(508) 754-3823
Fax
(508) 753-0151
NPI assigned
Nov 3, 2005
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 13, 2021

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

Authorized official

Name
Miss Lori Kixmiller
Title
Office Manager
Phone
(508) 754-3823

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
SpecialistGroup: 193400000X SINGLE SPECIALTY GROUP 174400000X 75849 MA Primary

Addresses

Primary practice location

100 Central St
Worcester, MA 01608-1209

Mailing address

100 Martin Luther King Jr Blvd
Worcester, MA 01608-1209
Phone (508) 754-3823

Other identifiers 2

IdentifierTypeStateIssuer
M17485OtherMABLUE SHIELD GROUP NUMBER
9700340MedicaidMA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050119000486 MA Part B Supplier - Clinic/Group Practice 4587613369 Receives reassigned benefits from 6 practitioners
Practice locations: Worcester, MA

National Provider Directory

National Provider Directory

Locations

100 Mlk Jr Blvd
Ste 110
Worcester, MA 01608

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1130976000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1613174400000",
    "number": "1144211681",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 MARTIN LUTHER KING JR BLVD",
            "city": "WORCESTER",
            "state": "MA",
            "postal_code": "016081209",
            "telephone_number": "508-754-3823",
            "fax_number": "508-753-0151"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 CENTRAL ST",
            "city": "WORCESTER",
            "state": "MA",
            "postal_code": "016081209",
            "telephone_number": "508-754-3823",
            "fax_number": "508-753-0151"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WORCESTER DERMATOLOGY ASSOCIATES, P.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-11-03",
        "last_updated": "2021-02-13",
        "certification_date": "2021-01-29",
        "status": "A",
        "authorized_official_last_name": "KIXMILLER",
        "authorized_official_first_name": "LORI",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "508-754-3823",
        "authorized_official_name_prefix": "Miss"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Specialist",
            "state": "MA",
            "license": "75849",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE SHIELD GROUP NUMBER",
            "identifier": "M17485",
            "state": "MA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "9700340",
            "state": "MA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Worcester, MA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 13, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.