Provider Demographics
NPI:1487671384
Name:PREMIER DERMATOLOGIC SURGERY, PA
Entity Type:Organization
Organization Name:PREMIER DERMATOLOGIC SURGERY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:SPENCERI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:913-327-1117
Mailing Address - Street 1:12200 W 106TH ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66215-2300
Mailing Address - Country:US
Mailing Address - Phone:913-327-1117
Mailing Address - Fax:913-327-1119
Practice Address - Street 1:12200 W 106TH ST
Practice Address - Street 2:SUITE 210
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66215-2300
Practice Address - Country:US
Practice Address - Phone:913-327-1117
Practice Address - Fax:913-327-1119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS30619207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS=========OtherTIN
KS=========OtherTIN