MEDICARE: ADVANCED DERMATOLOGY CARE MEDICAL COSMETIC AND SURGERY PA

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	207N00000X	Dermatology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C01783	OTHER	MN	PTAN

General Provider Information

NPI Number	:	1073614558
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED DERMATOLOGY CARE MEDICAL COSMETIC AND SURGERY PA

Provider Business Mailing Address
First Line	:	4480 CENTERVILLE RD
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55127-3674
Country	:	US
Telephone Number	:	651-484-2724
Fax Number	:	651-484-2723

Provider Business Practice Location Address
First Line	:	4480 CENTERVILLE RD
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55127-3674
Country	:	US
Telephone Number	:	651-484-2724
Fax Number	:	651-484-2723

Authorized Official
Title or Position	:	OWNER
Name	:	MR. OLAF J RUSTAD
Credential	:
Telephone Number	:	651-484-2724

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	11/16/2018

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