Provider Demographics
NPI:1962602326
Name:ADVANCED DERMATOLOGY AND SKIN SURGERY CENTER, LLC
Entity type:Organization
Organization Name:ADVANCED DERMATOLOGY AND SKIN SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SCHUEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-775-9000
Mailing Address - Street 1:5040 FOREST DR
Mailing Address - Street 2:STE 150
Mailing Address - City:NEW ALBANY
Mailing Address - State:OH
Mailing Address - Zip Code:43054-8167
Mailing Address - Country:US
Mailing Address - Phone:614-775-9000
Mailing Address - Fax:614-775-9002
Practice Address - Street 1:5040 FOREST DR
Practice Address - Street 2:STE 150
Practice Address - City:NEW ALBANY
Practice Address - State:OH
Practice Address - Zip Code:43054-8167
Practice Address - Country:US
Practice Address - Phone:614-775-9000
Practice Address - Fax:614-775-9002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35059547S207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHF35325Medicare UPIN
OHAD9373941Medicare PIN