Provider Demographics
NPI:1629442538
Name:SKIN SPECIALISTS
Entity Type:Organization
Organization Name:SKIN SPECIALISTS
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 PARKWAY NORTH
Mailing Address - Street 2:SUITE 240
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-4485
Mailing Address - Country:US
Mailing Address - Phone:763-367-7110
Mailing Address - Fax:
Practice Address - Street 1:825 NICOLLET MALL
Practice Address - Street 2:SUITE 1002
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-2614
Practice Address - Country:US
Practice Address - Phone:612-338-0711
Practice Address - Fax:612-332-3663
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:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty