Oliver Street Dermatology ASC LLC

Primary specialty

Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X

License

007937 Issued in TX

Legal business name

OLIVER STREET DERMATOLOGY ASC LLC

Doing business as

Dermatology Surgery Center

Practice address

1367 Dominion Plaza
Tyler, TX 75703-1013

Phone

(903) 534-6200

Fax

(903) 939-0755

NPI assigned

Jun 21, 2006

Organization subpart

No

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

Authorized official

Name

Ms. Andrea Lynne Stein, RN

Title

Practice Administrator

Phone

(903) 534-6200

Specialties & licenses 1

Addresses

Other identifiers 2

Other names 1

• Dermatology Surgery Center Doing business as

Medicare fee-for-service enrollment

Enrolled in TX

Enrollment records 1

Listed as

Dermatology Surgery CenterCCN 45C0001328

Medicare certification status

ActiveFrom the Provider of Services file

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

CLIA laboratory certificates

Locations

Practitioners 1

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

• Lawrence Lazelle Anderson, MD

  • Dermatology Physician
  • Tyler, TX
  • NPI 1134159627
  NPD (past)

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

{
    "created_epoch": "1150848000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1360108800000",
    "number": "1700822335",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1367 DOMINION PLAZA",
            "city": "TYLER",
            "state": "TX",
            "postal_code": "757031013",
            "telephone_number": "903-534-6200",
            "fax_number": "903-939-0755"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1367 DOMINION PLAZA",
            "city": "TYLER",
            "state": "TX",
            "postal_code": "757031013",
            "telephone_number": "903-534-6200",
            "fax_number": "903-939-0755"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "OLIVER STREET DERMATOLOGY ASC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-21",
        "last_updated": "2013-02-06",
        "status": "A",
        "authorized_official_last_name": "STEIN",
        "authorized_official_first_name": "ANDREA",
        "authorized_official_middle_name": "LYNNE",
        "authorized_official_title_or_position": "PRACTICE ADMINISTRATOR",
        "authorized_official_telephone_number": "903-534-6200",
        "authorized_official_name_prefix": "Ms.",
        "authorized_official_credential": "RN"
    },
    "taxonomies": [
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": "TX",
            "license": "007937",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE PTAN",
            "identifier": "P00044713",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "162384501",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Dermatology Surgery Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Grace Okegbola
• Christopher Okon Jr., PTA
• Sophia Olewunne
• Priscila Olguin
• Savannah Lea Olivarez, FNP-C
• Cody Bryan Oliver, LAT, ATC
• Hillary Oliver
• Latina Oliver
• Tarryn Oliver
• Olivero Care PLLC

• Ambulatory Surgical Clinic/Center in Tyler, TX
• Providers in Tyler, TX by specialty
• Ambulatory Surgical Clinic/Center in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 6, 2013; 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.