Healthcare Provider Details

I. General information

NPI: 1881875227
Provider Name (Legal Business Name): SKIN & MOHS SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2007
Last Update Date: 11/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3265 NE RALPH POWELL RD
LEES SUMMIT MO
64064-2301
US

IV. Provider business mailing address

3265 NE RALPH POWELL RD
LEES SUMMIT MO
64064-2301
US

V. Phone/Fax

Practice location:
  • Phone: 816-524-4747
  • Fax: 816-524-4929
Mailing address:
  • Phone: 816-524-4747
  • Fax: 816-524-9313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number188-0
License Number StateMO

VIII. Authorized Official

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