Provider Demographics
NPI:1073614558
Name:ADVANCED DERMATOLOGY CARE MEDICAL COSMETIC AND SURGERY PA
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY CARE MEDICAL COSMETIC AND SURGERY PA
Other - Org Name:ADVANCED DERMATOLOGY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:OLAF
Authorized Official - Middle Name:J
Authorized Official - Last Name:RUSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-484-2724
Mailing Address - Street 1:4480 CENTERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55127-3674
Mailing Address - Country:US
Mailing Address - Phone:651-484-2724
Mailing Address - Fax:651-484-2723
Practice Address - Street 1:4480 CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55127-3674
Practice Address - Country:US
Practice Address - Phone:651-484-2724
Practice Address - Fax:651-484-2723
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED DERMATOLOGY CARE MEDICAL AND SURGICAL DERMATOLOGY PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-26
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC01783OtherPTAN
MNC01783OtherPTAN
MND98155Medicare UPIN