Organization
ADVANCED DERMATOLOGY CARE MEDICAL COSMETIC AND SURGERY PA
Active
Other names
Advanced Dermatology Care
Organization subpart
No
Provider details
NPI number
Authorized official
DR. OLAF J RUSTAD M.D. (DERMATOLOGIST)
(651) 484-2724
Entity
Organization
Contact information
Practice address
25 LAKE ST N, SUITE 200, FOREST LAKE, MN 55025-2535
(651) 484-2724
Mailing address
4480 CENTERVILLE RD, SAINT PAUL, MN 55127-3674
(641) 484-2724
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
1376
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
070000195
PTAN
MN
01
—
C01783
GROUP LEGACY
MN
Enumeration date
10/07/2008
Last updated
01/11/2010
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