Basic Information
| Provider Information | |||||||||
| NPI: | 1689039836 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOREFRONT DERMATOLOGY, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 YORK ST | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542204630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206639016 | ||||||||
| FaxNumber: | 9206841439 | ||||||||
| Practice Location | |||||||||
| Address1: | 9209 PHOENIX VILLAGE PKWY | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6365614613 | ||||||||
| FaxNumber: | 6365614610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2015 | ||||||||
| LastUpdateDate: | 05/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | WERNLI | ||||||||
| AuthorizedOfficialFirstName: | BETSY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9204820671 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207NS0135X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.