MEDICARE: TWIN CITIES DERMATOPATHOLOGY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory
2	207ZD0900X	Dermatopathology (Pathology) Physician	1279	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	24D0651415	OTHER	CLIA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144223009
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TWIN CITIES DERMATOPATHOLOGY, LLC

Provider Business Mailing Address
First Line	:	9900 13TH AVENUE NORTH
Second Line	:	SUITE 2A
City	:	PLYMOUTH
State	:	MN
Zip	:	55441-5035
Country	:	US
Telephone Number	:	763-525-0363
Fax Number	:	763-525-0369

Provider Business Practice Location Address
First Line	:	9900 13TH AVENUE NORTH
Second Line	:	SUITE 2A
City	:	PLYMOUTH
State	:	MN
Zip	:	55441-5035
Country	:	US
Telephone Number	:	763-525-0363
Fax Number	:	763-525-0369

Authorized Official
Title or Position	:	BUSINESS ADMINISTRATOR
Name	:	LISA COOMBE
Credential	:
Telephone Number	:	763-525-0363

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	09/16/2024

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Directions to “TWIN CITIES DERMATOPATHOLOGY, LLC ” Practice Location

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