Provider Demographics
NPI:1700822335
Name:OLIVER STREET DERMATOLOGY ASC LLC
Entity Type:Organization
Organization Name:OLIVER STREET DERMATOLOGY ASC LLC
Other - Org Name:DERMATOLOGY SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:STEIN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:903-534-6200
Mailing Address - Street 1:1367 DOMINION PLAZA
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1013
Mailing Address - Country:US
Mailing Address - Phone:903-534-6200
Mailing Address - Fax:903-939-0755
Practice Address - Street 1:1367 DOMINION PLAZA
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1013
Practice Address - Country:US
Practice Address - Phone:903-534-6200
Practice Address - Fax:903-939-0755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX007937261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00044713OtherRAILROAD MEDICARE PTAN
TX162384501Medicaid
TXASC177Medicare PIN