MEDICARE: DERMATOLOGY GROUP OF SL 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	N2268	TX

General Provider Information

NPI Number	:	1790745198
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERMATOLOGY GROUP OF SL PA

Provider Business Mailing Address
First Line	:	15200 SOUTHWEST FWY
Second Line	:	SUITE 150
City	:	SUGAR LAND
State	:	TX
Zip	:	77478-3845
Country	:	US
Telephone Number	:	281-240-4313
Fax Number	:	281-240-3646

Provider Business Practice Location Address
First Line	:	15200 SOUTHWEST FWY
Second Line	:	SUITE 150
City	:	SUGAR LAND
State	:	TX
Zip	:	77478-3845
Country	:	US
Telephone Number	:	281-240-4313
Fax Number	:	281-240-3646

Authorized Official
Title or Position	:	OWNER
Name	:	EDWARD E. ROTAN JR.
Credential	:	M.D.
Telephone Number	:	281-240-4313

Provider Enumeration Date	:	03/28/2006
Last Update Date	:	08/11/2010

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