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General NPI Number Information
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NPI Number | 1366820136
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Entity Type | Organization
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Legal Business Name | INTEGRA DERMATOLOGY PA
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Dates
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Enumeration Date | 05/13/2015
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Last Update Date | 06/22/2021
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Provider Practice Location Address
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Address Line | 7373 FRANCE AVE S STE 510
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City | EDINA
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State | MN
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Zip | 55435-4551
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Country | US
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Telephone | 612-767-6000
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Fax |
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Provider Business Mailing Address
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Address Line | 7373 FRANCE AVE S STE 510
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City | EDINA
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State | MN
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Zip | 55435-4551
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Country | US
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Telephone | 612-767-6000
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Fax | 612-767-6600
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Authorized Official
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Title or Position | OWNER
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Name | DR. MIMI LAM
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Credential | MD
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Telephone | 612-767-6000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 1944
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License Number State | MN
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