Provider Demographics
NPI:1326150913
Name:LASER & SKIN SURGERY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:LASER & SKIN SURGERY MEDICAL GROUP INC
Other - Org Name:LASER & SKIN SURGERY CENTER OF NORTHERN CALIFORNIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:L
Authorized Official - Last Name:KILMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-456-0400
Mailing Address - Street 1:3835 J ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5520
Mailing Address - Country:US
Mailing Address - Phone:916-456-0400
Mailing Address - Fax:916-340-0621
Practice Address - Street 1:3835 J ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5520
Practice Address - Country:US
Practice Address - Phone:916-456-0400
Practice Address - Fax:916-340-0621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ14636ZMedicare PIN