MEDICARE: WHITE MOUNTAIN DERMATOLOGY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207NS0135X	Procedural Dermatology Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	070013565	OTHER	AZ	RAIL ROAD MEDICARE

General Provider Information

NPI Number	:	1033164538
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHITE MOUNTAIN DERMATOLOGY LLC

Provider Business Mailing Address
First Line	:	288 N IRONWOOD DR
Second Line	:	SUITE 105
City	:	APACHE JUNCTION
State	:	AZ
Zip	:	85220-3830
Country	:	US
Telephone Number	:	480-671-4086
Fax Number	:	480-671-4105

Provider Business Practice Location Address
First Line	:	288 N IRONWOOD DR
Second Line	:	SUITE 105
City	:	APACHE JUNCTION
State	:	AZ
Zip	:	85220-3830
Country	:	US
Telephone Number	:	480-671-4086
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GERARDO C BRUAL
Credential	:	MD
Telephone Number	:	480-671-4086

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	04/07/2015

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