1093913204 NPI number — MANISTEE DERMATOLOGY

Table of content: (NPI 1093913204)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093913204 NPI number — MANISTEE DERMATOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MANISTEE DERMATOLOGY
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:
1093913204
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2138 RELIABLE PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60686-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-398-1700
Provider Business Mailing Address Fax Number:
231-398-1709

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1293 E PARKDALE AVE
Provider Second Line Business Practice Location Address:
SUITE 2500
Provider Business Practice Location Address City Name:
MANISTEE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49660-8904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-398-1700
Provider Business Practice Location Address Fax Number:
231-398-1709
Provider Enumeration Date:
07/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NEIDER
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
DAWN
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
231-398-1700

Provider Taxonomy Codes

  • Taxonomy code: 173000000X , with the licence number:  4301086785 , 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)

  • Identifier: 104819846 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com