MEDICARE: NORTHLAND DERMATOLOGY 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	261QM2500X	Medical Specialty Clinic/Center	LC001419345	MO

General Provider Information

NPI Number	:	1639573561
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHLAND DERMATOLOGY LLC

Provider Business Mailing Address
First Line	:	6352 N COSBY AVE
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64151-2344
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6352 N COSBY AVE
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64151-2344
Country	:	US
Telephone Number	:	816-977-3677
Fax Number	:

Authorized Official
Title or Position	:	DERMATOLOGIST
Name	:	DR. CHRISTOPHER ROBERT ROUSE
Credential	:	M.D.
Telephone Number	:	816-977-3975

Provider Enumeration Date	:	10/21/2014
Last Update Date	:	10/21/2014

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