Provider Demographics
NPI:1467898007
Name:PREMIER DERMATOLOGY, LTD.
Entity Type:Organization
Organization Name:PREMIER DERMATOLOGY, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:ELLERBROEK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-233-3044
Mailing Address - Street 1:PO BOX 2400
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50704-2400
Mailing Address - Country:US
Mailing Address - Phone:319-234-6000
Mailing Address - Fax:319-234-6001
Practice Address - Street 1:3741 PHEASANT LN
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-5215
Practice Address - Country:US
Practice Address - Phone:319-234-6000
Practice Address - Fax:319-234-6001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-21
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty