Provider Demographics
NPI:1518331420
Name:SOUTHWEST DERMATOLOGY
Entity Type:Organization
Organization Name:SOUTHWEST DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:ZELICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-929-8888
Mailing Address - Street 1:2 CARLSON PKWY N STE 240
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-4485
Mailing Address - Country:US
Mailing Address - Phone:952-929-8888
Mailing Address - Fax:952-929-9669
Practice Address - Street 1:6425 NICOLLET AVENUE SOUTH
Practice Address - Street 2:SUITE 202
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-1668
Practice Address - Country:US
Practice Address - Phone:612-869-2086
Practice Address - Fax:612-869-4903
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNITED SKIN SPECIALISTS, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-11-17
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty