=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417163189
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACNE, SKIN DISEASE & LEG VEIN CLINIC, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2007
-----------------------------------------------------
Last Update Date | 08/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3960 COON RAPIDS BLVD NW SUITE 116
-----------------------------------------------------
City | COON RAPIDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55433-2569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-427-8113
-----------------------------------------------------
Fax | 763-427-8131
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3960 COON RAPIDS BLVD NW SUITE 116
-----------------------------------------------------
City | COON RAPIDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55433-2569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-427-8113
-----------------------------------------------------
Fax | 763-427-8131
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. THEODORE JOSEPH BUSELMEIER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 763-427-8113
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------