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General NPI Number Information
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NPI Number | 1912158031
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Entity Type | Organization
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Legal Business Name | ADVANCED DERMATOLOGY CARE MEDICAL COSMETIC AND SURGERY PA
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Dates
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Enumeration Date | 10/07/2008
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Last Update Date | 01/11/2010
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Provider Practice Location Address
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Address Line | 25 LAKE ST N SUITE 200
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City | FOREST LAKE
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State | MN
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Zip | 55025-2535
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Country | US
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Telephone | 651-484-2724
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Fax |
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Provider Business Mailing Address
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Address Line | 4480 CENTERVILLE RD
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City | SAINT PAUL
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State | MN
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Zip | 55127-3674
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Country | US
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Telephone | 641-484-2724
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Fax |
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Authorized Official
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Title or Position | DERMATOLOGIST
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Name | DR. OLAF J RUSTAD
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Credential | M.D.
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Telephone | 651-484-2724
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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 | 1376
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License Number State | MN
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