Provider Demographics
NPI:1871771998
Name:DERBY DERM
Entity type:Organization
Organization Name:DERBY DERM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WEIDE
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:316-788-3376
Mailing Address - Street 1:1121 N COLLEGE PARK ST
Mailing Address - Street 2:SUITE # 400
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-3665
Mailing Address - Country:US
Mailing Address - Phone:316-788-3376
Mailing Address - Fax:316-788-3378
Practice Address - Street 1:1121 N COLLEGE PARK ST
Practice Address - Street 2:SUITE # 400
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-3665
Practice Address - Country:US
Practice Address - Phone:316-788-3376
Practice Address - Fax:316-788-3378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1500761363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty