Provider Demographics
NPI:1912158031
Name:ADVANCED DERMATOLOGY CARE MEDICAL COSMETIC AND SURGERY PA
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY CARE MEDICAL COSMETIC AND SURGERY PA
Other - Org Name:ADVANCED DERMATOLOGY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DERMATOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:OLAF
Authorized Official - Middle Name:J
Authorized Official - Last Name:RUSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:651-484-2724
Mailing Address - Street 1:4480 CENTERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55127-3674
Mailing Address - Country:US
Mailing Address - Phone:641-484-2724
Mailing Address - Fax:
Practice Address - Street 1:25 LAKE ST N
Practice Address - Street 2:SUITE 200
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-2535
Practice Address - Country:US
Practice Address - Phone:651-484-2724
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1376207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC01783OtherGROUP LEGACY
MN070000195OtherPTAN
MND98155Medicare UPIN