Provider Demographics
NPI:1881875227
Name:SKIN & MOHS SURGERY CENTER, LLC
Entity type:Organization
Organization Name:SKIN & MOHS SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:913-451-7546
Mailing Address - Street 1:3265 NE RALPH POWELL RD
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64064-2301
Mailing Address - Country:US
Mailing Address - Phone:816-524-4747
Mailing Address - Fax:816-524-9313
Practice Address - Street 1:3265 NE RALPH POWELL RD
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64064-2301
Practice Address - Country:US
Practice Address - Phone:816-524-4747
Practice Address - Fax:816-524-4929
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OLIVER STREET DERMATOLOGY HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-14
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO188-0261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
9004294Medicare PIN