Healthcare Provider Details

I. General information

NPI: 1215985601
Provider Name (Legal Business Name): DERMATOLOGY SURGERY CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11623 ARBOR ST SUITE 102
OMAHA NE
68144-2981
US

IV. Provider business mailing address

11623 ARBOR ST SUITE 102
OMAHA NE
68144-2981
US

V. Phone/Fax

Practice location:
  • Phone: 402-330-4555
  • Fax: 402-330-4626
Mailing address:
  • Phone: 402-330-4555
  • Fax: 402-330-4626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberASC005
License Number StateNE

VIII. Authorized Official

Name: TERESA KAY DILTS
Title or Position: ADMINISTRATOR
Credential:
Phone: 402-330-4555