Provider Demographics
NPI:1255390548
Name:DERMATOLOGY, P.A.
Entity type:Organization
Organization Name:DERMATOLOGY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:W
Authorized Official - Last Name:IDE
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:952-374-5995
Mailing Address - Street 1:7300 FRANCE AVE SO
Mailing Address - Street 2:SUITE 400
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4544
Mailing Address - Country:US
Mailing Address - Phone:952-374-5995
Mailing Address - Fax:952-374-5997
Practice Address - Street 1:7300 FRANCE AVE SO
Practice Address - Street 2:SUITE 400
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4544
Practice Address - Country:US
Practice Address - Phone:952-374-5995
Practice Address - Fax:952-374-5997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC02695Medicare ID - Type Unspecified