Provider Demographics
NPI:1417088907
Name:DERMATOLOGY ASSOCIATES OF SIOUXLAND, PC
Entity Type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF SIOUXLAND, PC
Other - Org Name:DRS. ROSSITER & DEMAY, LLP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DERMATOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:J. MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:712-277-9370
Mailing Address - Street 1:2930 HAMILTON BLVD
Mailing Address - Street 2:STE. 102
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-2425
Mailing Address - Country:US
Mailing Address - Phone:712-277-9370
Mailing Address - Fax:712-252-4733
Practice Address - Street 1:2930 HAMILTON BLVD
Practice Address - Street 2:STE. 102
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104-2425
Practice Address - Country:US
Practice Address - Phone:712-277-9370
Practice Address - Fax:712-252-4733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA31906174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1417088907OtherWELLMARK BLUE CROSS & BLUE SHIELD GROUP NPI
IAIB2763OtherMEDICARE GROUP PTAN
IADT7736OtherMEDICARE RR GROUP PTAN