NPIMap

Organization Active NPI

Pennsylvania Centre for Dermatology, LLC

  • Dermatology Physician
  • Philadelphia, PA
National Provider Identifier
1861501801
Registry record updated Oct 4, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
License
MD421221 Issued in PA
Legal business name
PENNSYLVANIA CENTRE FOR DERMATOLOGY, LLC
Practice address
822 Pine St
Suite 2a
Philadelphia, PA 19107-6187
Phone
(267) 519-0154
Fax
(267) 519-0597
NPI assigned
Aug 30, 2006
Last updated
Oct 4, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 4, 2011

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

Authorized official

Name
Dr. Glen H Crawford, MDNPI 1598780165
Title
President
Phone
(267) 519-0154

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology Physician 207N00000X MD421221 PA Primary

Addresses

Primary practice location

822 Pine St
Suite 2a
Philadelphia, PA 19107-6187

Mailing address

PO Box 22624
Philadelphia, PA 19110-2624
Phone (267) 519-0154

Other identifiers 3

IdentifierTypeStateIssuer
1607671OtherPAHIGHMARK BLUE SHIELD
2295672000OtherIBC
3679792OtherPAAETNA

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040720000493 PA Part B Supplier - Clinic/Group Practice 4183603335 Receives reassigned benefits from 62 practitioners
Practice locations: King of Prussia, PA; Philadelphia, PA; North Wales, PA; Meadowbrook, PA; Kennett Square, PA; Exton, PA; Coatesville, PA; Bala Cynwyd, PA…

National Provider Directory

National Provider Directory

Locations

701 E Baltimore Pike
Kennett Square, PA 19348
Phone (610) 444-0070

800 Spruce St
Fl 10
Philadelphia, PA 19107
Phone 2157327600102

822 Pine St
Lowr
Philadelphia, PA 19107
Phone (267) 519-0154

822 Pine St
Ste 2A
Philadelphia, PA 19107
Phone (267) 519-0154

Practitioners & affiliated clinicians

Practitioners 83

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.

View all 83

NPI Registry JSON

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

{
    "created_epoch": "1156896000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1317686400000",
    "number": "1861501801",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 22624",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191102624",
            "telephone_number": "267-519-0154",
            "fax_number": "267-519-0597"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "822 PINE ST",
            "address_2": "SUITE 2A",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191076187",
            "telephone_number": "267-519-0154",
            "fax_number": "267-519-0597"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PENNSYLVANIA CENTRE FOR DERMATOLOGY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-30",
        "last_updated": "2011-10-04",
        "status": "A",
        "authorized_official_last_name": "CRAWFORD",
        "authorized_official_first_name": "GLEN",
        "authorized_official_middle_name": "H",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "267-519-0154",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "PA",
            "license": "MD421221",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HIGHMARK BLUE SHIELD",
            "identifier": "1607671",
            "state": "PA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "IBC",
            "identifier": "2295672000",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AETNA",
            "identifier": "3679792",
            "state": "PA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Philadelphia, PA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 4, 2011; 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.