Provider Demographics
NPI:1093913204
Name:MANISTEE DERMATOLOGY
Entity Type:Organization
Organization Name:MANISTEE DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:NEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-398-1700
Mailing Address - Street 1:2138 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0001
Mailing Address - Country:US
Mailing Address - Phone:231-398-1700
Mailing Address - Fax:231-398-1709
Practice Address - Street 1:1293 E PARKDALE AVE
Practice Address - Street 2:SUITE 2500
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-8904
Practice Address - Country:US
Practice Address - Phone:231-398-1700
Practice Address - Fax:231-398-1709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086785173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104819846Medicaid
MI0P26510Medicare PIN