Provider Demographics
NPI:1043391188
Name:SKIN SURGERY CENTER PS
Entity Type:Organization
Organization Name:SKIN SURGERY CENTER PS
Other - Org Name:SKIN SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:BRIERLEY
Authorized Official - Last Name:ODLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-346-6647
Mailing Address - Street 1:1229 MADISON ST
Mailing Address - Street 2:SUITE 1480
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-3586
Mailing Address - Country:US
Mailing Address - Phone:206-346-6647
Mailing Address - Fax:206-346-6022
Practice Address - Street 1:1229 MADISON ST
Practice Address - Street 2:SUITE 1480
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3586
Practice Address - Country:US
Practice Address - Phone:206-346-6647
Practice Address - Fax:206-346-6022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
7070SKOtherBCBS
WA=========OtherEIN
WAGAB17739Medicare PIN