Provider Demographics
NPI:1023063906
Name:EASTSIDE DERMATOLOGY SERVICES P.C.
Entity type:Organization
Organization Name:EASTSIDE DERMATOLOGY SERVICES P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:G
Authorized Official - Last Name:GERONEMUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-686-7306
Mailing Address - Street 1:317 E 34TH ST
Mailing Address - Street 2:11TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-4974
Mailing Address - Country:US
Mailing Address - Phone:212-686-7306
Mailing Address - Fax:212-686-7305
Practice Address - Street 1:317 E 34TH ST
Practice Address - Street 2:11TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-4974
Practice Address - Country:US
Practice Address - Phone:212-686-7306
Practice Address - Fax:212-686-7305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWER161Medicare PIN