Provider Demographics
NPI:1427079516
Name:DERMATOLOGY CLINIC S.C.
Entity type:Organization
Organization Name:DERMATOLOGY CLINIC S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT TO THE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:ZIMMERMANN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:920-406-9803
Mailing Address - Street 1:715 SUPERIOR RD STE 120
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-7595
Mailing Address - Country:US
Mailing Address - Phone:920-406-9803
Mailing Address - Fax:920-406-9934
Practice Address - Street 1:715 SUPERIOR RD STE 120
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-7595
Practice Address - Country:US
Practice Address - Phone:920-406-9803
Practice Address - Fax:920-406-9934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207N00000X
WI2187-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21251100Medicaid
WI21251100Medicaid
WI21251100Medicaid