Organization
PALM CANYON DERMATOLOGY, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. GREGORY ANDREW ERTL M.D. (PRESIDENT/OWNER)
(928) 344-0650
Entity
Organization
Contact information
Practice address
350 W CATALINA DR, YUMA, AZ 85364-8112
(928) 344-0650
(928) 344-3928
Mailing address
350 W CATALINA DR, YUMA, AZ 85364-8112
(928) 344-0650
(928) 344-3928
Taxonomy
Speciality
Code
Description
License number
State
305S00000X
Point of Service
Primary
19732
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
CG5646
RAIL ROAD MEDICARE
—
Enumeration date
11/07/2007
Last updated
11/16/2007
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