Provider Demographics
NPI:1114192754
Name:ROCHESTER DERMATOLOGY CLINIC, P.C.
Entity Type:Organization
Organization Name:ROCHESTER DERMATOLOGY CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:CLARENCE
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-853-3131
Mailing Address - Street 1:56853 MOUNT VERNON RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-4829
Mailing Address - Country:US
Mailing Address - Phone:248-652-3926
Mailing Address - Fax:248-853-3275
Practice Address - Street 1:405 BARCLAY CIR
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-4573
Practice Address - Country:US
Practice Address - Phone:248-843-3131
Practice Address - Fax:248-853-3275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101005759207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty