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Organization
OLIVER STREET DERMATOLOGY ASC LLC
Active
Organization
OLIVER STREET DERMATOLOGY ASC LLC
Active
Other names
Dermatology Surgery Center
Organization subpart
No
Provider details
NPI number
Authorized official
MS. ANDREA LYNNE STEIN RN (PRACTICE ADMINISTRATOR)
(903) 534-6200
Entity
Organization
Contact information
Practice address
1367 DOMINION PLAZA, TYLER, TX 75703-1013
(903) 534-6200
(903) 939-0755
Mailing address
1367 DOMINION PLAZA, TYLER, TX 75703-1013
(903) 534-6200
(903) 939-0755
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
007937
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
162384501
—
TX
01
—
P00044713
RAILROAD MEDICARE PTAN
TX
Enumeration date
06/21/2006
Last updated
02/06/2013
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