Healthcare Provider Details

I. General information

NPI: 1689039836
Provider Name (Legal Business Name): FOREFRONT DERMATOLOGY, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2015
Last Update Date: 05/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9209 PHOENIX VILLAGE PKWY
O FALLON MO
63368
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 636-561-4613
  • Fax: 636-561-4610
Mailing address:
  • Phone: 920-663-9016
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BETSY J WERNLI
Title or Position: PRESIDENT
Credential: MD
Phone: 920-482-0671