Provider Demographics
NPI:1710321633
Name:NEW DERMATOLOGY GROUP LTD
Entity Type:Organization
Organization Name:NEW DERMATOLOGY GROUP LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:KEVAN
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-965-0345
Mailing Address - Street 1:2021 S WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2257
Mailing Address - Country:US
Mailing Address - Phone:920-965-0345
Mailing Address - Fax:920-273-6011
Practice Address - Street 1:440 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-4631
Practice Address - Country:US
Practice Address - Phone:920-965-0345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW DERMATOLOGY GROUP LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-22
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty