Provider Demographics
NPI:1497765762
Name:CENTER FOR ADVANCED DERMATOLOGY LLC
Entity Type:Organization
Organization Name:CENTER FOR ADVANCED DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAELA
Authorized Official - Middle Name:W
Authorized Official - Last Name:MCDONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-989-5231
Mailing Address - Street 1:3455 S YARROW ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80227
Mailing Address - Country:US
Mailing Address - Phone:303-989-5231
Mailing Address - Fax:303-989-9785
Practice Address - Street 1:3455 S YARROW ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80227
Practice Address - Country:US
Practice Address - Phone:303-989-5231
Practice Address - Fax:303-989-9785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC368308Medicare PIN