Basic Information
| Provider Information | |||||||||
| NPI: | 1013197862 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACADEMIC DERMATOLOGY & MOHS SURGERY SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4555 W SCHROEDER DR | ||||||||
| Address2: | SUITE 170 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532231475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143653210 | ||||||||
| FaxNumber: | 4143653225 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 N MAYFAIR RD | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142583376 | ||||||||
| FaxNumber: | 4144756647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2007 | ||||||||
| LastUpdateDate: | 03/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | GHARIA | ||||||||
| AuthorizedOfficialFirstName: | MANISH | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4142583376 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 34248400 | 05 | WI | MEDICAID |