Provider Demographics
NPI:1265583652
Name:ADVANCED SPECIALTY ASSOCIATES, LTD
Entity type:Organization
Organization Name:ADVANCED SPECIALTY ASSOCIATES, LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KURTIS
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:218-454-8888
Mailing Address - Street 1:13359 ISLE DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-2221
Mailing Address - Country:US
Mailing Address - Phone:218-454-8888
Mailing Address - Fax:
Practice Address - Street 1:13359 ISLE DR
Practice Address - Street 2:SUITE 1
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-2221
Practice Address - Country:US
Practice Address - Phone:218-454-8888
Practice Address - Fax:888-835-7231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37843207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN930218200Medicaid
MN422K7WAOtherBLUE CROSS BLUE SHIELD MN