Provider Demographics
NPI:1306196548
Name:DERMATOLOGY PROFESSIONALS PA
Entity Type:Organization
Organization Name:DERMATOLOGY PROFESSIONALS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KUGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-454-3065
Mailing Address - Street 1:13359 ISLE DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-2222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15167 EDGEWOOD DR
Practice Address - Street 2:SUITE 200
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56401-6946
Practice Address - Country:US
Practice Address - Phone:218-454-7546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DERMATOLOGY PROFESSIONALS PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45453261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC04747Medicare PIN