Provider Demographics
NPI:1003016312
Name:ADVANCED DERMATOLOGIC SURGERY, P.A.
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGIC SURGERY, P.A.
Other - Org Name:ADVANCED DERMATOLOGIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:ALBERS
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:913-661-1755
Mailing Address - Street 1:6901 W 121ST ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66209-2007
Mailing Address - Country:US
Mailing Address - Phone:913-661-1755
Mailing Address - Fax:913-661-9260
Practice Address - Street 1:6901 W 121ST ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66209-2007
Practice Address - Country:US
Practice Address - Phone:913-661-1755
Practice Address - Fax:913-661-9260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-25136174400000X, 291U00000X
207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
17D0890923OtherCLIA #