Healthcare Provider Details

I. General information

NPI: 1427079516
Provider Name (Legal Business Name): DERMATOLOGY CLINIC S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 SUPERIOR RD STE 120
GREEN BAY WI
54311-7595
US

IV. Provider business mailing address

715 SUPERIOR RD STE 120
GREEN BAY WI
54311-7595
US

V. Phone/Fax

Practice location:
  • Phone: 920-406-9803
  • Fax: 920-406-9934
Mailing address:
  • Phone: 920-406-9803
  • Fax: 920-406-9934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2187-023
License Number StateWI

VIII. Authorized Official

Name: MR. CHRIS L ZIMMERMANN
Title or Position: ASSISTANT TO THE PRESIDENT
Credential: PHD
Phone: 920-406-9803