=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760206437
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOREFRONT DERMATOLOGY SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2024
-----------------------------------------------------
Last Update Date | 11/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 E 3RD ST
-----------------------------------------------------
City | FARMVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23901-1510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-607-4599
-----------------------------------------------------
Fax | 434-363-4191
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 YORK ST
-----------------------------------------------------
City | MANITOWOC
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54220-4630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-663-9008
-----------------------------------------------------
Fax | 920-684-1439
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BETSY J WERNLI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 920-482-0671
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------