1083155501 NPI number — FOREFRONT DERMATOLOGY, S.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083155501 NPI number — FOREFRONT DERMATOLOGY, S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOREFRONT DERMATOLOGY, S.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083155501
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 YORK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANITOWOC
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54220-4630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-663-7190
Provider Business Mailing Address Fax Number:
920-684-1439

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1005 PENNSYLVANIA AVE
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
OTTUMWA
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-683-3195
Provider Business Practice Location Address Fax Number:
641-686-3197
Provider Enumeration Date:
03/16/2017

Additional Information

Authorized Official

Authorized Official Last Name:
WERNLI
Authorized Official First Name:
BETSY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
920-482-0671

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207NS0135X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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