NPIMap

Organization Active NPI

Aqua Dermatology of Alabama PC

Doing business as Sunrise Dermatology

  • MOHS-Micrographic Surgery Physician
  • Vestavia HLS, AL
National Provider Identifier
1477708642
Registry record updated Jun 25, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
MOHS-Micrographic Surgery PhysicianTaxonomy code 207ND0101X
License
20579 Issued in AL
Legal business name
AQUA DERMATOLOGY OF ALABAMA PC
Doing business as
Sunrise Dermatology
Surgical Dermatology Group
True Dermatology
Practice address
1940 Stonegate Dr Ste 130
Vestavia HLS, AL 35242
Phone
(205) 977-9876
Fax
(205) 977-9976
NPI assigned
Dec 1, 2008
Last updated
Jun 25, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 25, 2024

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

Authorized official

Name
Karen Lake
Title
Administration
Phone
(205) 977-9786

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology Physician 207N00000X 20579 AL
MOHS-Micrographic Surgery Physician 207ND0101X 20579 AL Primary
Procedural Dermatology Physician 207NS0135X 20579 AL

Addresses

Primary practice location

1940 Stonegate Dr Ste 130
Vestavia HLS, AL 35242

Mailing address

1940 Stonegate Dr Ste 130
Vestavia HLS, AL 35242-2541
Phone (205) 977-9876

Other names 3

  • Sunrise Dermatology Doing business as
  • Surgical Dermatology Group Doing business as
  • True Dermatology Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AL, MS2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20081229000234 AL Part B Supplier - Clinic/Group Practice 9436211463 Receives reassigned benefits from 58 practitioners
Practice locations: Vestavia HLS, AL; Troy, AL; Pell City, AL; Oxford, AL; Muscle Shoals, AL; Montgomery, AL; Mobile, AL; Jasper, AL…
O20220228000358 MS Part B Supplier - Clinic/Group Practice 9436211463 Receives reassigned benefits from 1 practitioner
Practice locations: Columbus, MS

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
01D1092927Aqua Dermatology of Alabama PC1940 Stonegate Drive, Suite 130, Vestavia Hills, AL 35242ComplianceJun 22, 2027

National Provider Directory

National Provider Directory

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Locations

2172 Moores Mill Rd
Auburn, AL 36830
Phone (334) 887-5036

4933 Promenade Pkwy
Ste 105
Bessemer, AL 35022
Phone (205) 624-2100

801 Princeton Ave SW
Ste 520
Birmingham, AL 35211
Phone (205) 776-8600

1205 County Road 1466
Ste 110
Cullman, AL 35058

1301 Bridge Creek Dr NE
#A
Cullman, AL 35055
Phone (256) 841-3105

820 W Washington St
Ste 130
Eufaula, AL 36027

450 Century Park S
Ste 200
Hoover, AL 35226
Phone (205) 624-2100

4021 Balmoral Dr SW
Huntsville, AL 35801
Phone (256) 382-0070

1722 Pine St
Ste 400
Montgomery, AL 36106
Phone (205) 453-4195

7300 Halcyon Summit Dr
Montgomery, AL 36117

41 Eminence Way
Ste 110
Pell City, AL 35128

801 S Franklin Dr
Ste 130
Troy, AL 36081

1400 Urban Center Dr
Ste 120
Vestavia, AL 35242

1940 Stonegate Dr
Ste 130
Vestavia Hls, AL 35242
Phone (205) 451-9481

1940 Stonegate Dr
Ste 140
Vestavia Hls, AL 35242
Phone (205) 968-3919

Practitioners & affiliated clinicians

Practitioners 70

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 70

NPI Registry JSON

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

{
    "created_epoch": "1228089600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1719273600000",
    "number": "1477708642",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1940 STONEGATE DR STE 130",
            "city": "VESTAVIA HLS",
            "state": "AL",
            "postal_code": "352422541",
            "telephone_number": "205-977-9876",
            "fax_number": "205-977-9976"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1940 STONEGATE DR STE 130",
            "city": "VESTAVIA HLS",
            "state": "AL",
            "postal_code": "35242",
            "telephone_number": "205-977-9876",
            "fax_number": "205-977-9976"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AQUA DERMATOLOGY OF ALABAMA PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-12-01",
        "last_updated": "2024-06-25",
        "certification_date": "2024-06-25",
        "status": "A",
        "authorized_official_last_name": "LAKE",
        "authorized_official_first_name": "KAREN",
        "authorized_official_title_or_position": "ADMINISTRATION",
        "authorized_official_telephone_number": "205-977-9786"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "AL",
            "license": "20579",
            "primary": false
        },
        {
            "code": "207ND0101X",
            "taxonomy_group": "",
            "desc": "Dermatology, MOHS-Micrographic Surgery",
            "state": "AL",
            "license": "20579",
            "primary": true
        },
        {
            "code": "207NS0135X",
            "taxonomy_group": "",
            "desc": "Dermatology, Procedural Dermatology",
            "state": "AL",
            "license": "20579",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Sunrise Dermatology",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Surgical Dermatology Group",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "True Dermatology",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Vestavia HLS, AL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 25, 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.