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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