Provider Demographics
NPI:1851516397
Name:SKIN CARE DOCTORS, P.A.
Entity Type:Organization
Organization Name:SKIN CARE DOCTORS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:EBERTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-898-1600
Mailing Address - Street 1:14000 NICOLLET AVE STE 304
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-5784
Mailing Address - Country:US
Mailing Address - Phone:952-898-1600
Mailing Address - Fax:952-898-2645
Practice Address - Street 1:14000 NICOLLET AVE STE 304
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-5784
Practice Address - Country:US
Practice Address - Phone:952-898-1600
Practice Address - Fax:952-898-2645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC02848OtherMEDICARE PTAN
MNCH6529OtherRAILROAD MEDICARE
MN57238OtherHEALTH PARTNERS
MNE180OtherUCARE
MN09G0SKOtherBLUE CROSS BLUE SHIELD