Basic Information
| Provider Information | |||||||||
| NPI: | 1003209248 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AZEAL DERMATOLOGY INSTITUTE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7446 | ||||||||
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| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805370446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706632742 | ||||||||
| FaxNumber: | 9706670847 | ||||||||
| Practice Location | |||||||||
| Address1: | 5365 SPINE RD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803013324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035309325 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2015 | ||||||||
| LastUpdateDate: | 09/15/2015 | ||||||||
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| AuthorizedOfficialLastName: | PILKINGTON | ||||||||
| AuthorizedOfficialFirstName: | STACEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3035309325 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0101X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207NS0135X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 207N00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 77885376 | 05 | CO | MEDICAID |