Provider Demographics
NPI:1124045075
Name:HEIDELBERG DERMATOLOGY, P.C.
Entity Type:Organization
Organization Name:HEIDELBERG DERMATOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:A
Authorized Official - Last Name:HEIDELBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-864-3766
Mailing Address - Street 1:20400 LIVERNOIS AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-1348
Mailing Address - Country:US
Mailing Address - Phone:313-864-3766
Mailing Address - Fax:313-864-8134
Practice Address - Street 1:20400 LIVERNOIS AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-1348
Practice Address - Country:US
Practice Address - Phone:313-341-4514
Practice Address - Fax:313-341-2152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066952207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H28011OtherBLUE CROSS SHIELD MICHIGA
MI0H28011Medicare ID - Type Unspecified
MI0H28011OtherBLUE CROSS SHIELD MICHIGA