Provider Demographics
NPI:1881167278
Name:ADVANCED DERMATOLOGY CLINIC, INC.
Entity type:Organization
Organization Name:ADVANCED DERMATOLOGY CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARATA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:608-826-0285
Mailing Address - Street 1:6510 GRAND TETON PLZ STE 302
Mailing Address - Street 2:
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:608-826-0281
Practice Address - Street 1:1036 W STEPHENSON ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-4865
Practice Address - Country:US
Practice Address - Phone:888-423-7880
Practice Address - Fax:608-826-0281
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED DERMATOLOGY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-08
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty