MEDICARE: MERIT DERMATOLOGY, S.C.

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	2086S0122X	Plastic and Reconstructive Surgery Physician
2	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1649664434
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERIT DERMATOLOGY, S.C.

Provider Business Mailing Address
First Line	:	6233 BANKERS RD
Second Line	:	SUITE 3
City	:	MOUNT PLEASANT
State	:	WI
Zip	:	53403-9700
Country	:	US
Telephone Number	:	262-898-4419
Fax Number	:

Provider Business Practice Location Address
First Line	:	6233 BANKERS RD
Second Line	:	SUITE 20
City	:	MOUNT PLEASANT
State	:	WI
Zip	:	53403-9700
Country	:	US
Telephone Number	:	262-898-4400
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JAMES G DELIS
Credential	:	D.O.
Telephone Number	:	847-414-7010

Provider Enumeration Date	:	03/19/2015
Last Update Date	:	03/19/2015

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