NPIMap

Organization Active NPI

Advanced Dermatology Care Medical Cosmetic and Surgery PA

Doing business as Advanced Dermatology Care

  • Dermatology Physician
  • White Bear Lake, MN
National Provider Identifier
1073614558
Registry record updated Nov 16, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
ADVANCED DERMATOLOGY CARE MEDICAL COSMETIC AND SURGERY PA
Doing business as
Advanced Dermatology Care
Practice address
4480 Centerville Rd
White Bear Lake, MN 55127-3674
Phone
(651) 484-2724
Fax
(651) 484-2723
NPI assigned
Sep 26, 2006
Last updated
Nov 16, 2018By the provider in NPPES
Organization subpart
Yes
Parent organization
ADVANCED DERMATOLOGY CARE MEDICAL AND SURGICAL DERMATOLOGY PAAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 16, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Olaf J RustadNPI 1174586440
Title
Owner
Phone
(651) 484-2724

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology Physician 207N00000X Primary

Addresses

Primary practice location

4480 Centerville Rd
White Bear Lake, MN 55127-3674

Mailing address

4480 Centerville Rd
White Bear Lake, MN 55127-3674
Phone (651) 484-2724

Other identifiers 1

IdentifierTypeStateIssuer
C01783OtherMNPTAN

Other names 1

  • Advanced Dermatology Care Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040511000150 MN Part B Supplier - Clinic/Group Practice 4385633767 Receives reassigned benefits from 16 practitioners
2 other NPIs on this enrollment
Practice locations: Forest Lake, MN; Stillwater, MN; White Bear Lake, MN

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
24D0897250Advanced Dermatology Care4480 Centerville Rd, White Bear Lake, MN 55127ComplianceMay 13, 2027

National Provider Directory

National Provider Directory
Part of
Advanced Skin Care Inst

Practitioners & affiliated clinicians

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 16

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1159228800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1542326400000",
    "number": "1073614558",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4480 CENTERVILLE RD",
            "city": "WHITE BEAR LAKE",
            "state": "MN",
            "postal_code": "551273674",
            "telephone_number": "651-484-2724",
            "fax_number": "651-484-2723"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4480 CENTERVILLE RD",
            "city": "WHITE BEAR LAKE",
            "state": "MN",
            "postal_code": "551273674",
            "telephone_number": "651-484-2724",
            "fax_number": "651-484-2723"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ADVANCED DERMATOLOGY CARE MEDICAL COSMETIC AND SURGERY PA",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ADVANCED DERMATOLOGY CARE MEDICAL AND SURGICAL DERMATOLOGY PA",
        "enumeration_date": "2006-09-26",
        "last_updated": "2018-11-16",
        "status": "A",
        "authorized_official_last_name": "RUSTAD",
        "authorized_official_first_name": "OLAF",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "651-484-2724",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PTAN",
            "identifier": "C01783",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Advanced Dermatology Care",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Advanced Dermatology Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in White Bear Lake, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 16, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.