Healthcare Provider Details

I. General information

NPI: 1235480112
Provider Name (Legal Business Name): NEW DERMATOLOGY GROUP LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 12/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 S WEBSTER AVE
GREEN BAY WI
54301-2257
US

IV. Provider business mailing address

2221 S WEBSTER AVE SUITE 241
GREEN BAY WI
54301-2158
US

V. Phone/Fax

Practice location:
  • Phone: 920-965-0345
  • Fax: 920-273-6011
Mailing address:
  • Phone: 920-965-0345
  • Fax: 920-273-6011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: KEVAN G LEWIS
Title or Position: OWNER
Credential: MD
Phone: 920-965-0345