Provider Demographics
NPI:1265535140
Name:BEAVERCREEK DERMATOLOGY LLC
Entity type:Organization
Organization Name:BEAVERCREEK DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:V
Authorized Official - Last Name:BALAZS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:937-427-4600
Mailing Address - Street 1:3572 DAYTON-XENIA RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45432-2838
Mailing Address - Country:US
Mailing Address - Phone:937-427-4600
Mailing Address - Fax:937-427-4520
Practice Address - Street 1:3572 DAYTON-XENIA RD
Practice Address - Street 2:SUITE 105
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45432-2838
Practice Address - Country:US
Practice Address - Phone:937-427-4600
Practice Address - Fax:937-427-4520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
BE9338791Medicare ID - Type Unspecified