Healthcare Provider Details

I. General information

NPI: 1740241595
Provider Name (Legal Business Name): CENTER FOR DERMATOLOGIC SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 WESTERN HILLS BLVD
CHEYENNE WY
82009-3446
US

IV. Provider business mailing address

123 WESTERN HILLS BLVD
CHEYENNE WY
82009-3446
US

V. Phone/Fax

Practice location:
  • Phone: 307-635-0226
  • Fax: 307-635-1924
Mailing address:
  • Phone: 307-635-0226
  • Fax: 307-635-1924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SANDRA K SURBRUGG
Title or Position: OWNER
Credential: MD
Phone: 307-635-0226