Healthcare Provider Details

I. General information

NPI: 1992738124
Provider Name (Legal Business Name): DERMATOLOGY & ADVANCED SKIN CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 07/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6021 UNIVERSITY BLVD SUITE 390
ELLICOTT CITY MD
21043-6077
US

IV. Provider business mailing address

6021 UNIVERSITY BLVD SUITE 390
ELLICOTT CITY MD
21043-6077
US

V. Phone/Fax

Practice location:
  • Phone: 410-203-0607
  • Fax: 410-203-0677
Mailing address:
  • Phone: 410-203-0607
  • Fax: 410-203-0677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberD0030058
License Number StateMD

VIII. Authorized Official

Name: ELISA RUSONIS
Title or Position: ADMINISTRATOR
Credential:
Phone: 410-203-0607