Basic Information
| Provider Information | |||||||||
| NPI: | 1356411524 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SKINPHYSICIANS & SURGEONS MEDICAL GROUP, INC. | ||||||||
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| OtherOrganizationName: | SKINPHYSICIANS & SURGEONS, A FOREFRONT DERMATOLOGY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 YORK ST | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542204630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206639008 | ||||||||
| FaxNumber: | 9206841439 | ||||||||
| Practice Location | |||||||||
| Address1: | 859 E FOOTHILL BLVD STE B | ||||||||
| Address2: | |||||||||
| City: | UPLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917864085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099818929 | ||||||||
| FaxNumber: | 9099469740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | WERNLI | ||||||||
| AuthorizedOfficialFirstName: | BETSY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9204820671 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | A76057 | CA | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207ND0101X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.