Provider Demographics
NPI:1902205206
Name:AFFILIATED DERMATOLOGISTS
Entity Type:Organization
Organization Name:AFFILIATED DERMATOLOGISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/AFFILIATED DERMATOLOGISTS
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-754-4488
Mailing Address - Street 1:13800 W NORTH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4977
Mailing Address - Country:US
Mailing Address - Phone:262-754-4488
Mailing Address - Fax:262-754-4940
Practice Address - Street 1:N96W17035 DIVISION RD
Practice Address - Street 2:SUITE A
Practice Address - City:GERMANTOWN
Practice Address - State:WI
Practice Address - Zip Code:53022-6419
Practice Address - Country:US
Practice Address - Phone:262-754-4488
Practice Address - Fax:262-754-4940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-22
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1407849011OtherBILLING NPI NUMBER