Provider Demographics
NPI:1053461137
Name:CENTER OF DERMATOLOGY, PC
Entity Type:Organization
Organization Name:CENTER OF DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HERSCHEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:STOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-398-9200
Mailing Address - Street 1:10110 NICHOLAS STREET
Mailing Address - Street 2:SUITE #103
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2185
Mailing Address - Country:US
Mailing Address - Phone:402-398-9200
Mailing Address - Fax:402-398-9400
Practice Address - Street 1:10110 NICHOLAS STREET
Practice Address - Street 2:SUITE #103
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2185
Practice Address - Country:US
Practice Address - Phone:402-398-9200
Practice Address - Fax:402-398-9400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NENE13516207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========02Medicaid
NE=========02Medicaid
NEB67761Medicare UPIN