Provider Demographics
NPI:1285792788
Name:DERMATOLOGY AND DERMATOLOGIC SURGERY CENTER, PC
Entity type:Organization
Organization Name:DERMATOLOGY AND DERMATOLOGIC SURGERY CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KNOKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-225-8180
Mailing Address - Street 1:8131 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-1123
Mailing Address - Country:US
Mailing Address - Phone:515-225-8180
Mailing Address - Fax:515-225-2041
Practice Address - Street 1:8131 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-1123
Practice Address - Country:US
Practice Address - Phone:515-225-8180
Practice Address - Fax:515-225-2041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA11181Medicare ID - Type Unspecified