Provider Demographics
NPI:1164662730
Name:ACADEMIC DERMATOLOGY,PC
Entity Type:Organization
Organization Name:ACADEMIC DERMATOLOGY,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WHITNEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:TOPE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-746-6090
Mailing Address - Street 1:6545 FRANCE AVE S
Mailing Address - Street 2:SUITE 564
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2100
Mailing Address - Country:US
Mailing Address - Phone:952-746-6090
Mailing Address - Fax:
Practice Address - Street 1:6545 FRANCE AVE S
Practice Address - Street 2:SUITE 564
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2131
Practice Address - Country:US
Practice Address - Phone:952-746-6090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-23
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN38930174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN390822400Medicaid
MN070000288Medicare PIN
MN390822400Medicaid