MEDICARE: TWIN CITIES DERMATOLOGY CENTER, PA

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	207N00000X	Dermatology Physician	980103100020	MN

General Provider Information

NPI Number	:	1164930541
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TWIN CITIES DERMATOLOGY CENTER, PA

Provider Business Mailing Address
First Line	:	5000 W 36TH ST STE 205
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55416-2760
Country	:	US
Telephone Number	:	612-268-5005
Fax Number	:	612-268-5004

Provider Business Practice Location Address
First Line	:	5000 W 36TH ST STE 205
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55416-2760
Country	:	US
Telephone Number	:	919-282-6766
Fax Number	:

Authorized Official
Title or Position	:	INCORPORATOR
Name	:	MARGARETH PIERRE-LOUIS
Credential	:	MD
Telephone Number	:	612-268-5005

Provider Enumeration Date	:	01/19/2018
Last Update Date	:	04/03/2018

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