Healthcare Provider Details

I. General information

NPI: 1962602326
Provider Name (Legal Business Name): ADVANCED DERMATOLOGY AND SKIN SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5040 FOREST DR STE 150
NEW ALBANY OH
43054-8167
US

IV. Provider business mailing address

5040 FOREST DR STE 150
NEW ALBANY OH
43054-8167
US

V. Phone/Fax

Practice location:
  • Phone: 614-775-9000
  • Fax: 614-775-9002
Mailing address:
  • Phone: 614-775-9000
  • Fax: 614-775-9002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number35059547S
License Number StateOH

VIII. Authorized Official

Name: WENDY D SCHUEN
Title or Position: OWNER
Credential: MD
Phone: 614-775-9000