Provider Demographics
NPI:1144486978
Name:ADVANCED DERMATOLOGY CARE MEDICAL COSMETIC AND SURGERY PA
Entity type:Organization
Organization Name:ADVANCED DERMATOLOGY CARE MEDICAL COSMETIC AND SURGERY PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DERMATOLOGIST PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OLAF
Authorized Official - Middle Name:JONATHAN
Authorized Official - Last Name:RUSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:651-484-2724
Mailing Address - Street 1:4480 CENTERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WHITE BEARLAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55127
Mailing Address - Country:US
Mailing Address - Phone:651-484-2724
Mailing Address - Fax:651-484-2724
Practice Address - Street 1:14130 60TH ST N
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6354
Practice Address - Country:US
Practice Address - Phone:651-484-2724
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-31
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1376207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC01783OtherGROUP LEGACY
MN070000195OtherPTAN
MND98155Medicare UPIN