Provider Demographics
NPI:1295783496
Name:DERMATOLOGY SERVICES, SC
Entity type:Organization
Organization Name:DERMATOLOGY SERVICES, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SIDNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HERSZENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-258-3500
Mailing Address - Street 1:3077 N MAYFAIR RD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-4305
Mailing Address - Country:US
Mailing Address - Phone:414-258-3500
Mailing Address - Fax:414-258-3501
Practice Address - Street 1:3077 N MAYFAIR RD
Practice Address - Street 2:SUITE 305
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-4305
Practice Address - Country:US
Practice Address - Phone:414-258-3500
Practice Address - Fax:414-258-3501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18537207N00000X
207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21303900Medicaid
CS0892OtherRR MEDICARE
WI000052255Medicare PIN
WI21303900Medicaid