Provider Demographics
NPI:1073607925
Name:KALAMAZOO DERMATOLOGY, P.C.
Entity Type:Organization
Organization Name:KALAMAZOO DERMATOLOGY, P.C.
Other - Org Name:KALAMAZOO DERMATOLOGY & SKIN CANCER CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-343-4679
Mailing Address - Street 1:6100 NEWPORT RD
Mailing Address - Street 2:STE 100
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-9235
Mailing Address - Country:US
Mailing Address - Phone:269-343-4679
Mailing Address - Fax:269-343-5929
Practice Address - Street 1:6100 NEWPORT RD
Practice Address - Street 2:STE 100
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-9235
Practice Address - Country:US
Practice Address - Phone:269-343-4679
Practice Address - Fax:269-343-5929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICA7827OtherPTAN
0C96019Medicare PIN