Provider Demographics
NPI:1366820136
Name:INTEGRA DERMATOLOGY PA
Entity Type:Organization
Organization Name:INTEGRA DERMATOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIMI
Authorized Official - Middle Name:
Authorized Official - Last Name:LAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-767-6000
Mailing Address - Street 1:7373 FRANCE AVE S STE 510
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4551
Mailing Address - Country:US
Mailing Address - Phone:612-767-6000
Mailing Address - Fax:612-767-6600
Practice Address - Street 1:7373 FRANCE AVE S STE 510
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4551
Practice Address - Country:US
Practice Address - Phone:612-767-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-13
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1944207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1944OtherMN STATE LICENSE