Provider Demographics
NPI:1487804258
Name:ASSOCIATED DERMATOLOGY AND HAIR CENTER
Entity type:Organization
Organization Name:ASSOCIATED DERMATOLOGY AND HAIR CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EARL
Authorized Official - Middle Name:UDO
Authorized Official - Last Name:BACHENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-749-7177
Mailing Address - Street 1:1844 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4611
Mailing Address - Country:US
Mailing Address - Phone:918-749-7177
Mailing Address - Fax:
Practice Address - Street 1:1844 E 15TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4611
Practice Address - Country:US
Practice Address - Phone:918-749-7177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-29
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1497207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK138329883Medicare Oscar/Certification
E07695Medicare UPIN