Healthcare Provider Details

I. General information

NPI: 1669577524
Provider Name (Legal Business Name): SKIN & MOHS SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 06/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11550 GRANADA ST
LEAWOOD KS
66211-1453
US

IV. Provider business mailing address

11550 GRANADA ST
LEAWOOD KS
66211-1453
US

V. Phone/Fax

Practice location:
  • Phone: 913-451-7546
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberS046023
License Number StateKS

VIII. Authorized Official

Name: DR. GLENN D GOLDSTEIN
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 913-451-7546