Provider Demographics
NPI:1811092398
Name:MIDWEST CLINIC OF DERMATOLOGY LASER AND COSMETIC SURGERY PA
Entity type:Organization
Organization Name:MIDWEST CLINIC OF DERMATOLOGY LASER AND COSMETIC SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:ELIEFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:320-259-0208
Mailing Address - Street 1:1510 24TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1304
Mailing Address - Country:US
Mailing Address - Phone:320-259-0208
Mailing Address - Fax:320-259-0715
Practice Address - Street 1:1510 24TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1304
Practice Address - Country:US
Practice Address - Phone:320-259-0208
Practice Address - Fax:320-259-0715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC08249Medicare ID - Type Unspecified