Provider Demographics
NPI:1740241595
Name:CENTER FOR DERMATOLOGIC SURGERY
Entity Type:Organization
Organization Name:CENTER FOR DERMATOLOGIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:SURBRUGG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-635-0226
Mailing Address - Street 1:123 WESTERN HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-3446
Mailing Address - Country:US
Mailing Address - Phone:307-635-0226
Mailing Address - Fax:307-635-1924
Practice Address - Street 1:123 WESTERN HILLS BLVD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-3446
Practice Address - Country:US
Practice Address - Phone:307-635-0226
Practice Address - Fax:307-635-1924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW307677Medicare ID - Type Unspecified