Basic Information
| Provider Information | |||||||||
| NPI: | 1518331420 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST DERMATOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4100 W 50TH ST | ||||||||
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| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554241200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529298888 | ||||||||
| FaxNumber: | 9529299669 | ||||||||
| Practice Location | |||||||||
| Address1: | 6425 NICOLLET AVENUE SOUTH | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | RICHFIELD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554231668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128692086 | ||||||||
| FaxNumber: | 6128694903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2015 | ||||||||
| LastUpdateDate: | 11/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | ZELICKSON | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9529298888 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNITED SKIN SPECIALISTS, LTD | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207NS0135X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology |
No ID Information.