Provider Demographics
NPI:1497182273
Name:ADVANCED DERMATOLOGY OF THE MIDLANDS PC
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY OF THE MIDLANDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHEHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FAAD
Authorized Official - Phone:402-933-3770
Mailing Address - Street 1:2213 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-5305
Mailing Address - Country:US
Mailing Address - Phone:515-237-3974
Mailing Address - Fax:515-883-2692
Practice Address - Street 1:12910 PIERCE ST STE 120
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-1106
Practice Address - Country:US
Practice Address - Phone:402-933-3770
Practice Address - Fax:402-933-3633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-10
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1497182273Medicaid
NE100263840-00Medicaid
IAIB3010Medicare PIN
NENA2455Medicare PIN