Basic Information
| Provider Information | |||||||||
| NPI: | 1720370166 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED MEDICAL AND SURGICAL DERMATOLOGY CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1099 D ST STE 204 | ||||||||
| Address2: | |||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949012893 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152590131 | ||||||||
| FaxNumber: | 4152590133 | ||||||||
| Practice Location | |||||||||
| Address1: | 1099 D ST STE 204 | ||||||||
| Address2: | |||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949012893 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152590131 | ||||||||
| FaxNumber: | 4152590133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2011 | ||||||||
| LastUpdateDate: | 05/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | BANDT | ||||||||
| AuthorizedOfficialFirstName: | ANYA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4152590131 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0101X | A65186 | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207ND0900X | A65186 | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207NI0002X | A65186 | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Clinical & Laboratory Dermatological Immunology | 207NS0135X | A65186 | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 207N00000X | A65185 | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.