Basic Information
| Provider Information | |||||||||
| NPI: | 1073614558 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED DERMATOLOGY CARE MEDICAL COSMETIC AND SURGERY PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADVANCED DERMATOLOGY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4480 CENTERVILLE RD | ||||||||
| Address2: | |||||||||
| City: | WHITE BEAR LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551273674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514842724 | ||||||||
| FaxNumber: | 6514842723 | ||||||||
| Practice Location | |||||||||
| Address1: | 4480 CENTERVILLE RD | ||||||||
| Address2: | |||||||||
| City: | WHITE BEAR LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551273674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514842724 | ||||||||
| FaxNumber: | 6514842723 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 11/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | RUSTAD | ||||||||
| AuthorizedOfficialFirstName: | OLAF | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6514842724 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADVANCED DERMATOLOGY CARE MEDICAL AND SURGICAL DERMATOLOGY PA | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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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 | C01783 | 01 | MN | PTAN | OTHER |