Provider Demographics
NPI:1083785877
Name:DERMATOLOGY CENTER PC
Entity Type:Organization
Organization Name:DERMATOLOGY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BONINO
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:313-937-1200
Mailing Address - Street 1:25510 PLYMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-2025
Mailing Address - Country:US
Mailing Address - Phone:313-937-1200
Mailing Address - Fax:
Practice Address - Street 1:25510 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-2025
Practice Address - Country:US
Practice Address - Phone:313-937-1200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N97880Medicare ID - Type Unspecified