Provider Demographics
NPI:1871541078
Name:DERMATOLOGY SURGERY CENTER PC
Entity type:Organization
Organization Name:DERMATOLOGY SURGERY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:DILTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-330-4555
Mailing Address - Street 1:909 N 96TH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2497
Mailing Address - Country:US
Mailing Address - Phone:402-330-4555
Mailing Address - Fax:
Practice Address - Street 1:909 N 96TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2497
Practice Address - Country:US
Practice Address - Phone:402-330-4555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========13Medicaid
NEH40274Medicare UPIN
NE=========13Medicaid
NEQ15714Medicare UPIN
NE0988852Medicare ID - Type UnspecifiedGROUP PRACTICE NUMBER