Provider Demographics
NPI:1437339470
Name:PALM CANYON DERMATOLOGY, PC
Entity type:Organization
Organization Name:PALM CANYON DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:ERTL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-344-0650
Mailing Address - Street 1:350 W CATALINA DR
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-8112
Mailing Address - Country:US
Mailing Address - Phone:928-344-0650
Mailing Address - Fax:928-344-3928
Practice Address - Street 1:350 W CATALINA DR
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-8112
Practice Address - Country:US
Practice Address - Phone:928-344-0650
Practice Address - Fax:928-344-3928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19732305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CG5646OtherRAIL ROAD MEDICARE
CG5646OtherRAIL ROAD MEDICARE