MEDICARE: MIDWEST DERMATOLOGY INCORPORATED PC

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	18006	OK

General Provider Information

NPI Number	:	1821277666
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWEST DERMATOLOGY INCORPORATED PC

Provider Business Mailing Address
First Line	:	8855 E RENO AVENUE
Second Line	:	SUITE 200
City	:	MIDWEST CITY
State	:	OK
Zip	:	73110-7530
Country	:	US
Telephone Number	:	405-737-8877
Fax Number	:	405-737-4780

Provider Business Practice Location Address
First Line	:	8855 E RENO AVENUE
Second Line	:	SUITE 200
City	:	MIDWEST CITY
State	:	OK
Zip	:	73110-7724
Country	:	US
Telephone Number	:	405-737-8877
Fax Number	:	405-737-4780

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. STEVEN H SUTTER
Credential	:	MD
Telephone Number	:	405-737-8877

Provider Enumeration Date	:	10/29/2007
Last Update Date	:	04/30/2009

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