MEDICARE: DERMATOLOGY & ADVANCED SKIN CARE

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	174400000X	Specialist	D0030058	MD

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	553M860F	OTHER	MD	MEDICARE PTAN

General Provider Information

NPI Number	:	1992738124
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERMATOLOGY & ADVANCED SKIN CARE

Provider Business Mailing Address
First Line	:	6021 UNIVERSITY BLVD
Second Line	:	SUITE 390
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21043-6077
Country	:	US
Telephone Number	:	410-203-0607
Fax Number	:	410-203-0677

Provider Business Practice Location Address
First Line	:	6021 UNIVERSITY BLVD
Second Line	:	SUITE 390
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21043-6077
Country	:	US
Telephone Number	:	410-203-0607
Fax Number	:	410-203-0677

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	ELISA RUSONIS
Credential	:
Telephone Number	:	410-203-0607

Provider Enumeration Date	:	07/09/2006
Last Update Date	:	07/01/2010

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