Provider Demographics
NPI:1174799670
Name:VIRGINIA BEACH DERMATOLOGY ASSOCIATES PLLC
Entity type:Organization
Organization Name:VIRGINIA BEACH DERMATOLOGY ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:MR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:RYLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-301-8960
Mailing Address - Street 1:5320 PROVIDENCE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-4122
Mailing Address - Country:US
Mailing Address - Phone:757-523-4800
Mailing Address - Fax:757-523-5857
Practice Address - Street 1:5320 PROVIDENCE RD STE 202
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-4122
Practice Address - Country:US
Practice Address - Phone:757-523-4800
Practice Address - Fax:757-523-5857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033623207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005937108Medicaid
VA070000019Medicare PIN