NPIMap

Organization Active NPI

Dermatology Professionals PA

  • Clinic/Center
  • Baxter, MN
National Provider Identifier
1306196548
Registry record updated Jun 12, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
License
45453 Issued in MN
Legal business name
DERMATOLOGY PROFESSIONALS PA
Practice address
15167 Edgewood Dr
Suite 200
Baxter, MN 56401-6946
Phone
(218) 454-7546
NPI assigned
Sep 14, 2012
Organization subpart
Yes
Parent organization
DERMATOLOGY PROFESSIONALS PAAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jun 12, 2024

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

Authorized official

Name
Morgan Burgstaler
Title
Administrator
Phone
(218) 454-3065

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X 45453 MN Primary

Addresses

Primary practice location

15167 Edgewood Dr
Suite 200
Baxter, MN 56401-6946

Mailing address

13359 Isle Dr
Suite 3
Baxter, MN 56425-2222

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20071207000626 MN Part B Supplier - Clinic/Group Practice 4587753934 Receives reassigned benefits from 13 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Bemidji, MN; Brainerd, MN; East Gull Lake, MN; Grand Rapids, MN; Nisswa, MN; Saint Cloud, MN; Baxter, MN

Other NPIs on the same Medicare enrollment 4

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

National Provider Directory

National Provider Directory
Tax ID family
Dermatology Professionals4 organizations share this tax ID, including this one
Part of
Dermatology Professionals

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Locations

13359 Isle Dr
Ste 3
Baxter, MN 56425
Phone (218) 454-7546

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1347580800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1718150400000",
    "number": "1306196548",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "13359 ISLE DR",
            "address_2": "SUITE 3",
            "city": "BAXTER",
            "state": "MN",
            "postal_code": "564252222"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "15167 EDGEWOOD DR",
            "address_2": "SUITE 200",
            "city": "BAXTER",
            "state": "MN",
            "postal_code": "564016946",
            "telephone_number": "218-454-7546"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DERMATOLOGY PROFESSIONALS PA",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "DERMATOLOGY PROFESSIONALS PA",
        "enumeration_date": "2012-09-14",
        "last_updated": "2024-06-12",
        "certification_date": "2024-06-12",
        "status": "A",
        "authorized_official_last_name": "BURGSTALER",
        "authorized_official_first_name": "MORGAN",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "218-454-3065"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "MN",
            "license": "45453",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Baxter, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 12, 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.