Dermatology Professionals, PA

Primary specialty

Clinic/CenterTaxonomy code 261Q00000X

License

1699 Issued in MN

Legal business name

DERMATOLOGY PROFESSIONALS, PA

Practice address

2300 24TH St NW
Suite 110
Bemidji, MN 56601-6379

Phone

(218) 454-7546

NPI assigned

Nov 2, 2015

Last updated

Jun 12, 2024By the provider in NPPES

Organization subpart

No

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

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in MN

Enrollment records 1

Other NPIs on the same Medicare enrollment 4

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

• Dermatology Professionals PA

  • Clinic/Center
  • Baxter, MN
  • NPI 1306196548

  O20071207000626

  Same enrollment
• Dermatology Professionals PA

  • Clinic/Center
  • Saint Cloud, MN
  • NPI 1720840788

  O20071207000626

  Same enrollment
• Dermatology Professionals, PA

  • MOHS-Micrographic Surgery Physician
  • Grand Rapids, MN
  • NPI 1467169979

  O20071207000626

  Same enrollment
• Dermatology Professionals, PA

  • Clinic/Center
  • Baxter, MN
  • NPI 1720269426

  O20071207000626

  Same enrollment

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

CLIA laboratory certificates

Tax ID family

Dermatology Professionals4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

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

• Dermatology Professionals PA

  • Clinic/Center
  • Baxter, MN
  • NPI 1306196548
  NPD tax ID
• Dermatology Professionals PA

  • Clinic/Center
  • Saint Cloud, MN
  • NPI 1720840788
  NPD tax ID
• Dermatology Professionals, PA

  • MOHS-Micrographic Surgery Physician
  • Grand Rapids, MN
  • NPI 1467169979
  NPD tax ID

Locations

Practitioners 3

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.

• Katie Ann Reilley Greniger, MSN, FNP-BC

  • Internal Medicine Physician
  • Grand Rapids, MN
  • NPI 1356128524
  NPD
• Rebekah Rose White, CNP

  • Family Nurse Practitioner
  • Baxter, MN
  • NPI 1598744997
  NPD
• Paul Lundstrom, MD

  • Dermatology Physician
  • Baxter, MN
  • NPI 1699759647
  NPD (past)

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

{
    "created_epoch": "1446422400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1718150400000",
    "number": "1356714182",
    "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",
            "telephone_number": "218-454-7546"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2300 24TH ST NW",
            "address_2": "SUITE 110",
            "city": "BEMIDJI",
            "state": "MN",
            "postal_code": "566016379",
            "telephone_number": "218-454-7546"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DERMATOLOGY PROFESSIONALS, PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-11-02",
        "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": "1699",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "355427000",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Austin Decock, MS, LPCC
• Deep Rock Chiropractic PC
• Daniel Peter Dekrey, MD
• Pamela L Delancey, MS, ATC
• Rylie Jayne Demers
• Destiny Enterprises, LLC (A Touch of Home North)
• Joanne Carol Detwiler, L.A.D.C.
• Lindamulage Supun Dinithi Chandr Devaadithiya-Appuhamy, DNP, PMHNP-BC, CNP
• Jessica A. Dewey, LADC
• William G Dicks, MD

• Clinic/Center in Bemidji, MN
• Providers in Bemidji, MN by specialty
• Clinic/Center in Minnesota

• 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.
• 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.