MEDICARE: DERBY DERM

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	363A00000X	Physician Assistant	1500761	KS

General Provider Information

NPI Number	:	1871771998
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERBY DERM

Provider Business Mailing Address
First Line	:	1121 N COLLEGE PARK ST
Second Line	:	SUITE # 400
City	:	DERBY
State	:	KS
Zip	:	67037-3665
Country	:	US
Telephone Number	:	316-788-3376
Fax Number	:	316-788-3378

Provider Business Practice Location Address
First Line	:	1121 N COLLEGE PARK ST
Second Line	:	SUITE # 400
City	:	DERBY
State	:	KS
Zip	:	67037-3665
Country	:	US
Telephone Number	:	316-788-3376
Fax Number	:	316-788-3378

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. TIM WEIDE
Credential	:	P.A.
Telephone Number	:	316-788-3376

Provider Enumeration Date	:	01/31/2008
Last Update Date	:	01/31/2008

Similar Medicare Providers

1326986373 — JENNIFER T ALLEN APRN
Practice Location Address:

1121 N COLLEGE PARK ST
DERBY, KS
67037-3665

Practice Phone: 316-788-3376
Practice Fax:

1861600017 — MR. TIMOTHY L. WEIDE P.A.
Practice Location Address:

1121 N COLLEGE PARK ST , SUITE # 400
DERBY, KS
67037-3665

Practice Phone: 316-788-3376
Practice Fax: 316-788-3378

1346401973 — MRS. LINDSEY ANN MOSS LSCSW
Practice Location Address:

1121 N COLLEGE PARK ST , SUITE 200
DERBY, KS
67037-3665

Practice Phone: 316-650-5737
Practice Fax: 316-260-6494

1740911379 — MIRANDA MCDONALD
Practice Location Address:

1721 E OSAGE RD STE 300
DERBY, KS
67037-2290

Practice Phone: 316-247-3161
Practice Fax:

1053276071 — RESTORING HOPE COUNSELING LLC
Practice Location Address:

1721 E OSAGE RD STE 300
DERBY, KS
67037-2290

Practice Phone: 316-247-3161
Practice Fax:

1649988239 — ODRIKUS DONJUAN WELLS
Practice Location Address:

1525 N BUCKNER ST
DERBY, KS
67037-2948

Practice Phone: 316-788-6464
Practice Fax: 206-299-1262

Directions to “DERBY DERM ” Practice Location

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