Provider Demographics
NPI:1013197862
Name:ACADEMIC DERMATOLOGY & MOHS SURGERY SC
Entity Type:Organization
Organization Name:ACADEMIC DERMATOLOGY & MOHS SURGERY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MANISH
Authorized Official - Middle Name:J
Authorized Official - Last Name:GHARIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-258-3376
Mailing Address - Street 1:4555 W SCHROEDER DR
Mailing Address - Street 2:SUITE 170
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53223-1475
Mailing Address - Country:US
Mailing Address - Phone:414-365-3210
Mailing Address - Fax:414-365-3225
Practice Address - Street 1:201 N MAYFAIR RD
Practice Address - Street 2:SUITE 550
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4216
Practice Address - Country:US
Practice Address - Phone:414-258-3376
Practice Address - Fax:414-475-6647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34248400Medicaid
WI34248400Medicaid