Provider Demographics
NPI:1639162480
Name:AESTHETIC DERMATOLOGY & COSMETIC SURGERY MEDICAL ASSOCIATES, INC
Entity Type:Organization
Organization Name:AESTHETIC DERMATOLOGY & COSMETIC SURGERY MEDICAL ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REMOTE BUSINESS SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:LANOUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-484-7519
Mailing Address - Street 1:535 MILLER AVE
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-2905
Mailing Address - Country:US
Mailing Address - Phone:415-383-5486
Mailing Address - Fax:415-389-7455
Practice Address - Street 1:535 MILLER AVE
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-2905
Practice Address - Country:US
Practice Address - Phone:415-383-5486
Practice Address - Fax:415-389-7455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ94048ZMedicare PIN