Provider Demographics
NPI:1518171503
Name:VALLEY DERMATOLOGY CLINIC,S.C.
Entity Type:Organization
Organization Name:VALLEY DERMATOLOGY CLINIC,S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:FABER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-734-6880
Mailing Address - Street 1:412 E LONGVIEW DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-2145
Mailing Address - Country:US
Mailing Address - Phone:920-734-6880
Mailing Address - Fax:920-734-8867
Practice Address - Street 1:412 E LONGVIEW DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-2145
Practice Address - Country:US
Practice Address - Phone:920-734-6880
Practice Address - Fax:920-734-8867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31238800Medicaid
WI71-224Medicare ID - Type Unspecified
WI31238800Medicaid