NPIMap

Organization Active NPI

Advanced Dermatology Care Medical Cosmetic and Surgery PA

Doing business as Advanced Dermatology Care

  • Dermatology Physician
  • Stillwater, MN
National Provider Identifier
1144486978
Registry record updated Mar 11, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
License
1376 Issued in MN
Legal business name
ADVANCED DERMATOLOGY CARE MEDICAL COSMETIC AND SURGERY PA
Doing business as
Advanced Dermatology Care
Practice address
14130 60TH St N
Stillwater, MN 55082-6354
Phone
(651) 484-2724
NPI assigned
Jul 31, 2008
Last updated
Mar 11, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 11, 2024

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

Authorized official

Name
Olaf Jonathan Rustad, MDNPI 1174586440
Title
Dermatologist President
Phone
(651) 484-2724

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology Physician 207N00000X 1376 MN Primary

Addresses

Primary practice location

14130 60TH St N
Stillwater, MN 55082-6354

Mailing address

4480 Centerville Rd
White Bearlake, MN 55127
Phone (651) 484-2724

Other identifiers 2

IdentifierTypeStateIssuer
C01783OtherMNGROUP LEGACY
070000195OtherMNPTAN

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
This NPI is an additional NPI on the 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.

National Provider Directory

National Provider Directory

Locations

14130 60th St N
Stillwater, MN 55082
Phone (651) 484-2724

1970 Northwestern Ave S
Ste 300
Stillwater, MN 55082
Phone (651) 430-2724

Practitioners & affiliated clinicians

Practitioners 9

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.

NPI Registry JSON

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

{
    "created_epoch": "1217462400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1710115200000",
    "number": "1144486978",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4480 CENTERVILLE RD",
            "city": "WHITE BEARLAKE",
            "state": "MN",
            "postal_code": "55127",
            "telephone_number": "651-484-2724",
            "fax_number": "651-484-2724"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "14130 60TH ST N",
            "city": "STILLWATER",
            "state": "MN",
            "postal_code": "550826354",
            "telephone_number": "651-484-2724"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ADVANCED DERMATOLOGY CARE MEDICAL COSMETIC AND SURGERY PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-07-31",
        "last_updated": "2024-03-11",
        "certification_date": "2024-03-11",
        "status": "A",
        "authorized_official_last_name": "RUSTAD",
        "authorized_official_first_name": "OLAF",
        "authorized_official_middle_name": "JONATHAN",
        "authorized_official_title_or_position": "DERMATOLOGIST PRESIDENT",
        "authorized_official_telephone_number": "651-484-2724",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "MN",
            "license": "1376",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GROUP LEGACY",
            "identifier": "C01783",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PTAN",
            "identifier": "070000195",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Advanced Dermatology Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Stillwater, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 11, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.