Provider Demographics
NPI:1114950375
Name:J SEMMES MICKELWAIT MD PS
Entity Type:Organization
Organization Name:J SEMMES MICKELWAIT MD PS
Other - Org Name:ADVANCED DERMATOLOGY AND SKIN RENEWAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:J
Authorized Official - Middle Name:SEMMES
Authorized Official - Last Name:MICKELWAIT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-424-4186
Mailing Address - Street 1:1420 ROOSEVELT AVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-2687
Mailing Address - Country:US
Mailing Address - Phone:360-424-4186
Mailing Address - Fax:360-428-0927
Practice Address - Street 1:1420 ROOSEVELT AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-2687
Practice Address - Country:US
Practice Address - Phone:360-424-4186
Practice Address - Fax:360-428-0927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty