Provider Demographics
NPI:1770971350
Name:CITY DERMATOLOGY AND LASER
Entity type:Organization
Organization Name:CITY DERMATOLOGY AND LASER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LANA
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-421-3376
Mailing Address - Street 1:1 W 4TH ST
Mailing Address - Street 2:SUITE 2200
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-3604
Mailing Address - Country:US
Mailing Address - Phone:513-421-3376
Mailing Address - Fax:513-618-2128
Practice Address - Street 1:1 W 4TH ST
Practice Address - Street 2:SUITE 2200
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45202-3604
Practice Address - Country:US
Practice Address - Phone:513-421-3376
Practice Address - Fax:513-618-2128
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE SKIN CANCER CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.068727207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHF96275Medicare UPIN