Provider Demographics
NPI:1124763479
Name:DERMATOLOGY AND MOHS SURGERY SKIN CANCER CENTER
Entity type:Organization
Organization Name:DERMATOLOGY AND MOHS SURGERY SKIN CANCER CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ADRIENNE
Authorized Official - Middle Name:MICHELE
Authorized Official - Last Name:SCHUPBACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-533-8899
Mailing Address - Street 1:110 BUSINESS PARK DR STE C
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-7449
Mailing Address - Country:US
Mailing Address - Phone:417-336-0033
Mailing Address - Fax:855-710-6552
Practice Address - Street 1:110 BUSINESS PARK DR STE C
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-7449
Practice Address - Country:US
Practice Address - Phone:417-336-0033
Practice Address - Fax:417-239-0127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-02
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty