Provider Demographics
NPI:1851733521
Name:MARKET STREET DERMATOLOGY, PC
Entity Type:Organization
Organization Name:MARKET STREET DERMATOLOGY, PC
Other - Org Name:K & S DERMATOLOGY, PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAULS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-746-4144
Mailing Address - Street 1:275 MARKET ST
Mailing Address - Street 2:SUITE 215
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-1627
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:275 MARKET ST
Practice Address - Street 2:SUITE 215
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-1627
Practice Address - Country:US
Practice Address - Phone:612-746-4144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-23
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH100093120Medicare PIN