NPIMap

Organization Active NPI

Integrated Dermatology of Roseville, PC

  • Dermatology Physician
  • Roseville, CA
National Provider Identifier
1811586134
Registry record updated Jun 2, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
INTEGRATED DERMATOLOGY OF ROSEVILLE, PC
Practice address
1412 Blue Oaks Blvd
Roseville, CA 95747-7143
Phone
(916) 784-7546
Fax
(916) 784-7548
NPI assigned
Jan 12, 2021
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 2, 2021

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

Authorized official

Name
Jennifer T Haley, MD
Title
Authorized Group Official
Phone
(561) 314-2000

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207N00000X Primary

Addresses

Primary practice location

1412 Blue Oaks Blvd
Roseville, CA 95747-7143

Mailing address

4700 Exchange CT Ste 110
Boca Raton, FL 33431-4450
Phone (561) 314-2000

Other names 1

  • Select or enter Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210929003842 CA Part B Supplier - Clinic/Group Practice 3173930856 Receives reassigned benefits from 6 practitioners
Practice locations: Roseville, CA

National Provider Directory

National Provider Directory

Locations

1412 Blue Oaks Blvd
Roseville, CA 95747
Phone (916) 784-7546

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1610409600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1622592000000",
    "number": "1811586134",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4700 EXCHANGE CT STE 110",
            "city": "BOCA RATON",
            "state": "FL",
            "postal_code": "334314450",
            "telephone_number": "561-314-2000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1412 BLUE OAKS BLVD",
            "city": "ROSEVILLE",
            "state": "CA",
            "postal_code": "957477143",
            "telephone_number": "916-784-7546",
            "fax_number": "916-784-7548"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INTEGRATED DERMATOLOGY OF ROSEVILLE, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-01-12",
        "last_updated": "2021-06-02",
        "certification_date": "2021-06-02",
        "status": "A",
        "authorized_official_last_name": "HALEY",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_middle_name": "T",
        "authorized_official_title_or_position": "AUTHORIZED GROUP OFFICIAL",
        "authorized_official_telephone_number": "561-314-2000",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Select or enter",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Select or enter",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Roseville, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 2, 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.