Provider Demographics
NPI:1740303395
Name:ADVANCED DERMATOLOGY, INC.
Entity type:Organization
Organization Name:ADVANCED DERMATOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DERMATOLOGIST,MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:H
Authorized Official - Last Name:SHARATA
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:608-826-0825
Mailing Address - Street 1:6510 GRAND TETON PLZ
Mailing Address - Street 2:SUITE 302
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1029
Mailing Address - Country:US
Mailing Address - Phone:608-826-0285
Mailing Address - Fax:608-826-0280
Practice Address - Street 1:6510 GRAND TETON PLZ STE 302
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1029
Practice Address - Country:US
Practice Address - Phone:608-826-0285
Practice Address - Fax:608-826-0281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35716020174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIF92036Medicare UPIN