Provider Demographics
NPI:1255473815
Name:AESTHETIC DERMATOLOGY & LASER CENTER MEDICAL GROUP INC
Entity Type:Organization
Organization Name:AESTHETIC DERMATOLOGY & LASER CENTER MEDICAL GROUP INC
Other - Org Name:EDWARD M. KRAMER M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:KRAMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-229-8246
Mailing Address - Street 1:3055 W ORANGE AVE
Mailing Address - Street 2:#207
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-3159
Mailing Address - Country:US
Mailing Address - Phone:714-229-8246
Mailing Address - Fax:714-229-9362
Practice Address - Street 1:3055 W ORANGE AVE
Practice Address - Street 2:#207
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-3159
Practice Address - Country:US
Practice Address - Phone:714-229-8246
Practice Address - Fax:714-229-9362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57525207N00000X, 207ND0101X, 207ND0900X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15261Medicare ID - Type UnspecifiedGROUP ID#
CAA53299Medicare UPIN
CAWG57525FMedicare ID - Type UnspecifiedPPIN