1114192754 NPI number — ROCHESTER DERMATOLOGY CLINIC, P.C.

Table of content: (NPI 1114192754)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114192754 NPI number — ROCHESTER DERMATOLOGY CLINIC, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROCHESTER DERMATOLOGY CLINIC, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114192754
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
56853 MOUNT VERNON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHELBY TWP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48316-4829
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-652-3926
Provider Business Mailing Address Fax Number:
248-853-3275

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 BARCLAY CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48307-4573
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-843-3131
Provider Business Practice Location Address Fax Number:
248-853-3275
Provider Enumeration Date:
04/24/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BYRD
Authorized Official First Name:
ROGER
Authorized Official Middle Name:
CLARENCE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-853-3131

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  5101005759 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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