NPIMap

Organization Active NPI

Dermatology Professionals PA

  • Clinic/Center
  • Saint Cloud, MN
National Provider Identifier
1720840788
Registry record updated Jan 25, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
Legal business name
DERMATOLOGY PROFESSIONALS PA
Practice address
1511 Northway Dr Ste 103
Saint Cloud, MN 56303-1262
Phone
(218) 454-7546
Fax
(218) 454-0390
NPI assigned
Jan 25, 2024
Last updated
Jan 25, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 25, 2024

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

Authorized official

Name
Morgan Leigh Burgstaler
Title
Administrator
Phone
(218) 454-7546

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X NU Primary

Addresses

Primary practice location

1511 Northway Dr Ste 103
Saint Cloud, MN 56303-1262

Mailing address

13359 Isle Dr Ste 3
Baxter, MN 56425-2223
Phone (218) 454-7546

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.

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
24D2302735Dermatology Professionals1511 Northway Drive Suite 103, Saint Cloud, MN 56303Provider-performed microscopyMay 31, 2028

National Provider Directory

National Provider Directory
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.

Locations

15167 Edgewood Dr
Ste 200
Brainerd, MN 56401
Phone (218) 454-7546

1749 SE 2nd Ave
Grand Rapids, MN 55744
Phone (218) 326-5694

Practitioners & affiliated clinicians

Practitioners 13

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 13

NPI Registry JSON

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

{
    "created_epoch": "1706140800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1706140800000",
    "number": "1720840788",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "13359 ISLE DR STE 3",
            "city": "BAXTER",
            "state": "MN",
            "postal_code": "564252223",
            "telephone_number": "218-454-7546",
            "fax_number": "218-454-0390"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1511 NORTHWAY DR STE 103",
            "city": "SAINT CLOUD",
            "state": "MN",
            "postal_code": "563031262",
            "telephone_number": "218-454-7546",
            "fax_number": "218-454-0390"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DERMATOLOGY PROFESSIONALS PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-01-25",
        "last_updated": "2024-01-25",
        "certification_date": "2024-01-25",
        "status": "A",
        "authorized_official_last_name": "BURGSTALER",
        "authorized_official_first_name": "MORGAN",
        "authorized_official_middle_name": "LEIGH",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "218-454-7546"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Saint Cloud, MN

Sources for this page

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