Basic Information
| Provider Information | |||||||||
| NPI: | 1598348559 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOREFRONT DERMATOLOGY, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 YORK ST | ||||||||
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| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542204630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206639008 | ||||||||
| FaxNumber: | 9206841439 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 LINDEN AVE | ||||||||
| Address2: | |||||||||
| City: | WILMETTE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600912844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478433376 | ||||||||
| FaxNumber: | 8479988631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2021 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | ANGER | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. DIRECTOR, PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 9206639022 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207NS0135X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 207N00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.