1770973612 NPI number — ADVANCED DERMATOLOGY OF MICHIGAN, PC

Table of content: (NPI 1770973612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770973612 NPI number — ADVANCED DERMATOLOGY OF MICHIGAN, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED DERMATOLOGY OF MICHIGAN, PC
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:
1770973612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
151 SOUTHHALL LN
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
MAITLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32751-7176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-875-2080
Provider Business Mailing Address Fax Number:
407-650-3455

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13450 E 12 MILE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARREN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48088-3671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-759-5525
Provider Business Practice Location Address Fax Number:
586-759-4022
Provider Enumeration Date:
01/30/2015

Additional Information

Authorized Official

Authorized Official Last Name:
DECLUE
Authorized Official First Name:
AMY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR, PROVIDER SERVICES
Authorized Official Telephone Number:
407-875-2080

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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